Health inspection·August 18, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 9 residents (Resident #5, Resident #7, and Resident #9) reviewed for call lights in that: Residents Affected - Some Resident #5, Resident #7, and Resident #9 were observed in their rooms with call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Review of Resident #5's face sheet dated 8/18/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), Hypertension (high blood pressure), Neuropathy (weakness, numbness, and pain from nerve damage), Chronic Obstructive Pulmonary Disease (breathing disorder), Dysphagia (difficulty swallowing), Anemia (low red blood cells), Hyperlipidemia (high cholesterol) and Cognitive Communication Deficit. Review of Resident #5's MDS dated [DATE] reflected a short and long memory problem under section Staff Assessment for Mental Status . and reflected Resident #'s functional status as: required extensive assistance with transfers, dressing, toilet use and personal hygiene. Bathing was listed as total dependence and eating listed as supervision assistance for Resident #5. Review of Resident #5's care plan dated 8/18/2023 revealed the problems: Resident has the potential for falls related to right above the knee amputation. Interventions included: Keep call light in reach when in bed; Resident has an ADL Self Care performance Deficit and is at risk for not having their needs met in a timely manner. Intervention included: Encourage resident to use call light to call for assistance before attempting any ADLs. Review of Resident #7's face sheet dated 8/18/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (breathing disorder), Type 2 Diabetes (blood sugar disorder), Hyperlipidemia (high cholesterol), Difficulty in walking, Hypertension (high blood pressure), Peripheral Vascular Disease (blood circulation disorder), and Vascular Dementia (brain damage caused by strokes). Review of Resident #7's MDS dated [DATE] reflected A BIMS score of 4 indicating severe cognitive impairment . Resident #7's functional status reflected resident required no assistance for eating, Page 1 of 6 455631 455631 08/18/2023 Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031

F 0558 extensive assistance for dressing, toilet use, and personal hygiene; and total assistance for bathing. Level of Harm - Minimal harm or potential for actual harm Review of Resident #7's care plan dated 8/18/23 revealed it did not address the use of the call light for this resident. Residents Affected - Some Review of Resident #9's face sheet dated 8/18/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Congestive Heart Failure, Vascular Dementia (brain damage caused by strokes), History of Falling, Alzheimer's Disease (progressive memory loss disorder), Type 2 Diabetes (blood sugar disorder), Hypertension (high blood pressure), Stroke, Kidney Disease and Bipolar Disorder (behavioral health disorder). Review of Resident #9's MDS dated [DATE] reflected a BIMS of 8 indicating moderate cognitive impairment. Resident #9's function status reflected resident required no assistance for eating, extensive assistance for bathing and total dependence for dressing, toileting use and personal hygiene. Review of Resident #9's care plan dated 8/18/2023 revealed the problem: Resident has a communication problem related to Stroke; cerebral infarction. Interventions included: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, bed in lowest position and wheels locked, avoid isolation. During an observation in Resident #7's room on 8/18/2023 at 11:35 a.m., her call light was seen draped over her nightstand out of reach. During an interview with Resident #7 on 8/18/2023 at 11:35 a.m., she stated she could not reach the call light where it was laid on the nightstand and would have to yell to get help if she needed something. During an observation in Resident #9's room on 8/18/2023 at 11:58 a.m., his call light was seen clipped to the divider curtain out of reach. During an interview with Resident #9 on 8/18/2023 at 11:58 a.m., he stated he could not reach his call light from his bed but could yell if he needs help. He stated he knew how to use his call light and would get a staff to move it for him. During an observation in Resident #5's room on 8/18/2023 at 12:17 p.m., his call light was seen laying under the foot of his bed out of reach. During an interview with Resident #5 on 8/18/2023 at 12:17 p.m., Resident #5 stated he was doing ok but could not get to his call light. He stated he knew how to use the call light but would not be able to right now with it under the bed. During an interview with the DON on 8/18/2023 at 6:23 p.m., she stated her expectation was that staff would keep call lights in reach for residents to ensure their safety. She stated they have been in-serviced on this frequently and staff should follow the facility policy. Review of facility policy Call Light Response dated 2/10/2021 reflected The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet and bathing facility to allow residents to call for assistance. And further: 5. With reach 455631 Page 2 of 6 455631 08/18/2023 Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured as needed. Review of facility policy Resident Rights dated 2/20/2021 reflect The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 455631 Page 3 of 6 455631 08/18/2023 Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation, in that: The facility failed to ensure a 50-pound bag of onions was stored properly in the dry storage area. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings include: During an observation on 8/18/2023 at 12:22 p.m., in the kitchen hallway leading to the outside, a 50-pound netted bag of yellow onions was seen sitting directly on the floor. The netted bag was on the floor and the floor was observed to have debris on it. The bag was propped up against a wall that had visible dirt on it as well as brown stains near the base and a rusty nail laying between the bag and the base of the wall. During an interview on 8/18/2023 at 12:22 p.m., the Dietary Manager was shown the bag of onions on the floor and stated, I know, I know. She stated they just had a truck come in earlier that morning. She stated they had been short staffed and had not had time to put the onions away. She stated the facility policy states nothing (food) is to be stored on the floor. She stated the onions could get dirty, could get bugs in it, and could make the residents sick. Review of the facility policy Dry Food and Supplies Storage dated 11/15/2017 reflected The focus of protection for dry storage is to keep non-refrigerated food, disposable dishware, and napkins in a clean, dry area, which is free from contaminants. Food and food products should always be kept off the floor and clear of ceiling sprinklers, sewer/waste, disposal pipes and vents to maintain food quality and prevent contamination. 455631 Page 4 of 6 455631 08/18/2023 Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031

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 observation, interview, 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 for 1 of 2 residents (Resident #4) reviewed for blood sugar checks. Residents Affected - Few LVN A failed to appropriately sanitize her hands with ABHR and failed to appropriately clean Resident #4's finger with an alcohol pad before performing a blood sugar check. This failure could result in the spread of diseases to residents which could result in decreased quality of life, illness, and hospitalization. Findings include: Review of Resident #4's face sheet dated 8/18/2023, reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), Heart Disease, Hypertension (high blood pressure), Stroke, Chronic Kidney Disease, Hyperlipidemia (elevated levels of cholesterol), Anemia (low red blood cells) and Vascular Dementia (brain damage caused by strokes). Review of Resident #4's MDS dated [DATE] reflected in the Staff Assessment for Mental Status that resident had a short- and long-term memory problem. During a blood sugar observation on 8/18/2023 at 11:22 a.m., LVN A applied ABHR to her hands and then began fanning her hands in the air to dry them. LVN A then took an alcohol prep pad and wiped Resident #4's fingertip in preparation of a blood sugar check. Immediately after wiping Resident #4's fingertip, LVN A began fanning her hand over the fingertip to dry it. During an interview on 8/18/2023 at 11:25 a.m., LVN A stated she was not sure what the facility policy was for checking blood sugars. She stated she was not sure if the policy said you could fan your hands around in the air or fan a resident's finger after wiping with alcohol pad. She stated she had received training on infection control but was not aware if she could not fan her hands in the air to dry them. She stated she was not aware if it's allowed or not, it's just a habit I have. She was not able to verbalize the procedure for properly using ABHR to sanitize one's hands. She stated it could be an infection control issue for the resident. During an interview won 8/18/2023 at 2:14 p.m., the DON stated her expectation around blood sugar checks is that the nurse would not fan their hands because it doesn't allow time for the sanitizer to work if they don't let it dry without fanning. She stated it would be an infection control issue. She stated the same with a resident's finger, after wiping with an alcohol prep pad - they should not fan it; they should let it dry then take the blood sugar. She stated a negative outcome could be that it doesn't fully disinfect the site prior to puncturing the skin. Review of facility policy Hand Hygiene dated 2/11/2022 reflected: 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. B. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. C. This should take about 20 seconds. 455631 Page 5 of 6 455631 08/18/2023 Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031

F 0880 A policy on infection control was requested but not provided by the time of facility exit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455631 Page 6 of 6