Health inspection·June 28, 2023

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 an accurate MDS was completed for 3 of 16 residents (Residents #11, 13, and #14) reviewed for MDS assessment accuracy. Residents Affected - Some The facility did not accurately code Residents #11, #13, and #14's MDS for smoking when they were smokers. This failure could place residents who smoked at risk for not receiving care and services to meet their needs. Findings included: Record review of a list of residents who smoked was provided to the surveyors by the administrator upon entrance on 06/26/23 and indicated Residents #11, #13, and #14 were listed. 1. Record review of a face sheet dated 06/27/23 indicated Resident #11 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), 2019-nCoV acute respiratory disease (Covid 19 - infectious disease caused by the SARS virus), nicotine dependence (tobacco addiction), depression (medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent and excessive worry that interferes with daily activities), and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the annual MDS dated [DATE] for Resident #11 indicated under Section J J1300 Current Tobacco Use was marked 0 for No. Record review of a quarterly MDS dated [DATE], indicated Resident #11 was alert to person, time and place with a BIMS score of 11 which indicated moderately impaired. (Quarterly MDS do not address tobacco use.) Record review of Resident #11's care plan revised 5/22/2023 indicated Resident # 11 was a smoker with a goal that resident be allowed to smoke during designated smoking times with supervision. Record review of the most recent smoking risk assessment dated [DATE] for Resident #11 indicated under Observation Details: *Smoking Materials: Cigarettes Page 1 of 12 455642 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0641 *Frequency of Use: Couple times per day Level of Harm - Minimal harm or potential for actual harm During an interview on 06/26/23 at 3:30 p.m., Resident #11 indicated she smokes and does go out to designated area to smoke a cigarette during smoking times. Residents Affected - Some During an observation on 6/27/2023 at 2:00 p.m., Resident # 11 was outside the facility at the designated smoking area smoking a cigarette with supervision. During an observation on 6/28/2023 at 2:10 p.m., Resident # 11 was outside the facility at designated smoking area smoking a cigarette with supervision. 2. Record review of a face sheet dated 06/27/23 indicated Resident #13 was a [AGE] year-old male admitted on [DATE]. His diagnoses included schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and traumatic brain injury (a violent blow or jolt to the head). Record review of the admission MDS dated [DATE] for Resident #13 indicated under Section J J1300 Current Tobacco Use was marked 0 for No. Record review of a Smoking Risk assessment dated [DATE] for Resident #13 indicated under Observation Details: *Smoking Materials: Cigarettes *Frequency of Use: Couple times per day Record review of the care plan dated 04/20/23 indicated Resident #13 was a smoker with interventions including assess periodically that Resident #13 continued to be able to safely smoke. During an interview on 06/27/23 at 12:58 p.m., Resident #13 indicated he liked to go out and smoke a cigarette at times. 3. Record review of a face sheet dated 06/27/23 indicated Resident #14 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (loss of cognitive functioning) and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of an annual MDS dated [DATE] for Resident #14 indicated under Section J J1300 Current Tobacco Use was marked 1 for Yes. Record review of a Smoking Risk assessment dated [DATE] for Resident #14 indicated under Observation Details: *Smoking Materials: Cigarettes *Frequency of Use: Couple times per day Record review of an annual MDS dated [DATE] for Resident #14 indicated under Section J J1300 Current Tobacco Use was marked 0 for No. 455642 Page 2 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of the care plan dated 04/20/23 indicated Resident #14 was a smoker with interventions including assess periodically that Resident #14 continued to be a safe smoker. During an interview on 06/27/23 at 12:58 p.m., Resident #14 indicated he liked to go out and smoke a cigarette at times. Residents Affected - Some During an interview with the DON and the MDS nurse on 06/27/23 at 04:20 p.m., the MDS Nurse said she was responsible for completing the resident care plans and MDSs. She said she did not realize the MDSs for Residents #11, #13, and #14 were marked no for smoking. The DON said he and the MDS nurse came from a facility that was smoke-free so it was miscoded because they were used to not having smokers. They said MDS not coded correctly could have residents not assessed/evaluated for their needs. They said they used the CMS MDS Manual as their policy for the MDSs. 455642 Page 3 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0791 Provide or obtain dental services for each resident. 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 provide or obtain from an outside source dental services to meet the needs of 1 of 12 residents reviewed for dental services. (Resident #17) Residents Affected - Few The facility did not assist Resident #17, who had no teeth, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being. Findings included: Record review of face sheet and physician orders dated June 2023 indicated Resident #17, admitted [DATE], was [AGE] years old with diagnoses of chronic heart failure (a condition where the heart doesn't pump blood as well as it should) and diabetes (a disease in which the body's ability to produce and respond to insulin is impaired). The orders indicated the resident may have consult with a dentist. Record review of the most recent annual MDS assessment dated [DATE] indicated Resident #17 was cognitively intact and had no natural teeth or tooth fragments (edentulous). Record review of care plan dated 01/25/23 indicated Resident #17 was edentulous (lacking teeth) with interventions of monitoring intake and notify physician of significant weight loss. There were no dental service interventions listed. Record review of Resident #17's progress note dated 01/28/23 and signed by the facility's former social worker indicated the resident would like to be added to the list for dentures. Record review of the facility's grievance form dated 04/05/23 indicated Resident #17 wanted to be seen by a dentist and a dental visit was scheduled for 05/10/23. Record review of Resident #17's plan of care recommendation written by the dentist and dated 05/09/23 indicated, Patient is fully edentulous. I recommend upper and lower full dentures as teeth replacement prosthesis as medically necessary to restore proper mastication (chewing). During an observation and interview on 06/26/23 at 9:30 a.m., Resident #17 had no teeth. He said he had lost his dentures at the facility 8-10 months ago. He said he wanted to have dentures again, but nothing had been done to help him. During a telephone interview on 06/27/23 at 8:11 a.m., the SW said Resident #17 was seen by the dentist in May 2023 and she had not yet received the report from the dentist. She said she would contact the dentist's office and get the report and plan of care recommendations. She said she was not the SW at the facility when Resident #17 asked to be put on the list for dentures and she had no knowledge of that request. The SW said when a resident made a request for dentures she determined if the resident wanted to see an outside dentist or the dentist who came to the facility. She said after Resident #17 made his grievance report of wanting to see the dentist that visits the facility, she set up an appointment for him the next time the dentist would be at the facility. 455642 Page 4 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/28/23 at 8:22 a.m., the SW stated that after surveyor intervention she obtained the plan of care recommendation from the dentist and the recommendation and letter of explanation of payment for dentures will be given and explained to Resident #17 today 06/28/2023. She said the facility will schedule another appointment with the dentist and move forward with getting him dentures. During an interview on 06/28/23 at 8:55 a.m., the administrator said she had no knowledge of the request for dentures/seeing the dentist by Resident #17 on 01/28/23. She said it was the responsibility of the SW to make resident requested appointments and somehow Resident #17's request was not followed up on until he complained to her in April. She said the resident now had been seen by the dentist and a plan was in place for getting him dentures. She said she was the SW's direct supervisor and was responsible for the oversight. She said possible negative outcome of dental services being delayed could be weight loss. Facility policy titled Dental Services and last revised December 2016 indicated in part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 455642 Page 5 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food service. Residents Affected - Many The facility did not have clean pots, pans, skillets, baking sheets, baking pans, and steam table pans clean of encrusted grease deposits. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations of the kitchen on initial tour on 06/26/23 at: * 09:10 a.m. there were 5 large baking sheets, 2 medium baking sheets, 1 small baking sheets, 1 baking pan, 2 large deep steam table pans, and 5 large shallow steam table pans with dark brown/black buildup on the outside and inside stored on the bottom of the food prep table. * 09:12 a.m. there was 1 small skillet, 2 large skillets, and 3 saucepans were hanging on hanger. They had dark brown/black build up on the outside and inside of them. * 09:15 a.m. the gas stove had a large mid deep pan on the griddle with black buildup on the outside and inside of the pan and there was frying oil in the pan touching the black buildup. During an interview on 06/26/23 at 09:25 a.m,, the DM said she had tried to remove the buildup from the pots, pans, skillets, baking sheets, and steam table pans but was not able to get it off. Record review of the FDA Food Code 2022 (01/18/23 version) indicated: 4-6 Cleaning of Equipment and Utensils 4-601 Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations 455642 Page 6 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 3 of 3 residents (Residents #11, 13, and #14) reviewed for medical records. The facility failed to evaluate and document Residents #11, 13, and #14 as smokers and complete smoking assessments. This failure could place residents who smoke at risk of not having accurate documentation of smoking status and safety assessment. Findings included: Record review of a list of residents who smoked was provided to the surveyors by the ADM upon entrance on 06/26/23 and indicated Residents #11, #13, and #14 were listed. 1. Record review of a face sheet dated 06/27/23 indicated Resident #11 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), 2019-nCoV acute respiratory disease (Covid 19 - infectious disease caused by the SARS virus), nicotine dependence (tobacco addiction), depression (medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent and excessive worry that interferes with daily activities) and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of a quarterly MDS dated [DATE], indicated Resident #11 was alert to person, time and place with a BIMS score of 11 which indicated moderately impaired. (Quarterly MDS do not address tobacco use.) Record review of Resident #11's care plan revised 5/22/2023 indicated Resident # 11 was a smoker with a goal that resident be allowed to smoke during designated smoking times with supervision. Record review of the most recent smoking risk evaluation dated 10/09/22 for Resident #11 indicated under Observation Details: *Smoking Materials: Cigarettes *Frequency of Use: Couple times per day During an interview on 06/26/23 at 3:30 p.m., Resident #11 indicated she smokes and does go out to designated area to smoke a cigarette during smoking times. During an observation on 6/27/2023 at 2:00 p.m., Resident # 11 was outside the facility at the designated smoking area smoking a cigarette with supervision. During an observation on 6/28/2023 at 2:10 p.m., Resident # 11 was outside the facility at designated smoking area smoking a cigarette with supervision. 455642 Page 7 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of a face sheet dated 06/27/23 indicated Resident #13 was a [AGE] year-old male admitted on [DATE]. His diagnoses included schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and traumatic brain injury (a violent blow or jolt to the head). Record review of Resident # 13's EMR from 10/01/22 through 06/27/23 indicated there was one smoking evaluation found dated 10/09/22. During an observation and interview on 06/27/23 at 12:58 p.m., Resident #13 indicated he could not speak well but was able to say yes when he was asked if he liked to go out and smoke a cigarette at times. 3. Record review of a face sheet dated 06/27/23 indicated Resident #14 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (loss of cognitive functioning) and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident # 14's EMR from 09/01/22 through 06/27/23 indicated there was one smoking evaluation found dated 09/10/22. During an observation and interview on 06/27/23 at 12:58 p.m., Resident #14 indicated he said he liked to go out and smoke a cigarette at times. During an interview on 06/27/23 at 04:20 p.m., the MDS Nurse said there were no smoking evaluations found since October 2022. She said the nurses were expected to complete the smoking evaluations when they completed the other evaluations quarterly for the MDS assessment information. She said she was responsible for the residents' care plans and MDSs. She said she did not notice the smoking evaluations were not done. She said if a resident was not evaluated for hazards or risks of smoking and experienced a change or decline from the previous smoking evaluation, the resident was at risk of burning themselves or others. Record review of a Smoking Policy-Residents revised August 2022 indicated Policy Interpretation and Implementation: 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff 455642 Page 8 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. Residents Affected - Many The facility did not ensure the gas stove was in safe operating condition. Five of the 6 burners had residue and debris. This failure could place the residents at risk of a fire and not having safe operating equipment. Findings included: During observations on: * 06/26/23 at 09:15 AM the gas stove had front middle, front right side, and 3 back burners with black buildup and debris. * 06/27/23 at 11:36 AM the gas stove had front middle, front right side, and 3 back burners with black buildup and debris. During an interview on 06/28/23 at 10:25 a.m., the DM said the stove was deep cleaned at least monthly. She said she was going to have to come in on a weekend and scrub the stove to get the buildup off. During an interview on 06/28/23 02:08 p.m., the owner said he had bought the stove new a few months ago. Record review of the FDA Food Code 2022 (01/18/23 version) indicated the following: 4-6 Cleaning of Equipment and Utensils 4-601 Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris 455642 Page 9 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 10 window air conditioners (living room and dining room), 1 of 3 halls for unsecured chemicals (Hall A) and 16 of 35 windows screens (2 bent and 14 missing) and the grounds near the facility for unsecured chemicals reviewed for environment. 1. The facility failed to ensure gaps around the air conditioners were sealed to prevent pests, rodents and warm air from entering the facility. 2. The facility failed to ensure chemicals were in a secured location and flammable chemicals were stored in a secured location away from the facility. 3. The facility failed to ensure all window screens were intact for 16 of 35 windows. These failures could place residents, staff and visitors at risk of living, working or being in an unsafe, uncomfortable environment, infection and disease, and decreased quality of life due to poor conditions of the facility interior and exterior. Findings included: 1. During an observation on 06/26/23 at 8:20 a.m., the windows at the entryway indicated the window to the right of the doorway had no screen, 1 window before the window on the right had approximately a 5-6-inch gap in the screen, and the window to the left of the doorway had a screen with an open gap approximately 5-6 inches. The windows in the common area inside the entry indicated one window with an air conditioner window unit. It had an approximately 1/2-inch gap at the bottom of the window and the accordion expanding side was open approximately 3 inches which could allow areas available for insects and rodents to enter the facility. During an observation on 6/26/23 at 12:30 p.m., the air conditioner in the right window of the dining room had approximately 2-3-inch gaps below the air conditioner. The inside of the air conditioner was missing the partition that blocked vents from the outside, which could allow areas available for insects and rodents to enter the facility. During an observations on 06/27/23 at 9:05 a.m. and on 06/28/23 at 8:05 am, the windows at the entry way had a the window to the right of the doorway with no screen, 1 window before the window on the right had approximately a 5-6-inch gap in the screen, and the window to the left of the doorway had a screen with an open gap approximately 5-6 inches. The windows in the common area inside the entry reflected one window with an air conditioner window unit. It had an approximately 1/2-inch gap at the bottom of the window which could allow areas available for insects and rodents to enter the facility. During an interview on 06/28/23 at 09:35 AM, the ADM said she was at the facility on the weekend and installed the window units. She said MS told her she should have put foam trim around the units to cover any gaps in the window to prevent warm air or pest to enter the facility. 2. During an observations on 06/26/23 beginning at 9:41 a.m., the door to the maintenance room on 455642 Page 10 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hall A was closed and unlocked. The room contained a maintenance cart with 1/3 full quart metal can labeled lacquer thinner labeled danger .poison extremely flammable vapor . placed on top of the maintenance cart. The garbage can inside the maintenance room had 2 spray cans in the trash just inside the room and were labeled bug spray. The labels on the bug spray cans indicated to Keep out of reach of children and call poison control if ingested . There were no staff or residents in the hallway of Hall A. Rooms 1-13 on Hall A were resident rooms and the last 4 rooms of the hall were offices. During an interview and observation on 06/26/23 beginning at 9:43 a.m., the ADM said she found the MS's door unlocked this morning about an hour ago and it was the MS's responsibility for locking his door. She turned the MS doorknob, and it was unlocked. She said she had forgotten to lock it an hour ago. She said the maintenance door should be locked and flammable chemicals should be stored in the outside storage building. She said the door should be always locked when the MS was not in his office. 3. During an observation of the outside of the facility on 06/27/23 at 3:30 p.m. to 4:30 p.m., there were 14 of 35 windows with missing screens. There were 2 window screens bent and did not fully cover the windows. There were 2-quart bottles of lighter fluid, one was approximately 1/4 bottle full on picnic table seat which was 3 feet from the facility and the other bottle was about ¾ full and within 1 foot from the building on the ground. Both bottles of lighter fluid were labeled flammable and to keep out of reach of children. There was a ½ full 5-gallon thick plastic bottle with dark liquid. The container's label indicated the liquid was corrosive (a highly reactive substance that causes obvious damage to living tissue). During an interview and observation with the administrator and the MS on 6/27/23 beginning at 4:32 p.m., the administrator looked at the bottles of lighter fluid and said, we used the grill last weekend. The MS said all flammable chemicals should be stored in the storage building away from the facility. The MS and the administrator observed the ½ full 5-gallon thick plastic bottle with the dark liquid with the lid placed by the building. The MS said the 5-gallon container contained sulfuric acid and was used in toilets when the toilets were stopped up. The administrator said all chemicals should be locked up and stored properly away from the facility to prevent residents from getting hurt with chemicals. A Safety Data Sheet dated January 5,2015 indicated . Odorless charcoal lighter . may be fatal if swallowed and enters airway. Store locked up. Store in a well-ventilated place Keep cool. A Chemical Safety Data Sheet MSDS dated 6/27/23 indicated Sulfuric Acid . Store locked up. precautionary statements . if on skin remove/take of clothing immediately all contaminated clothing and rinse skin with water/shower. clothing hazard statement . causes severe skin burns . During an interview on 06/26/23 at 11:00 a.m., the administrator said the owner was planning to get new window screens, but no screens had been ordered. She said the facility did not have documentation of the plan for the screens to be ordered. During an interview on 06/28/23 at 02:08 p.m., the owner said he was aware of issues with the window screens and was working on trying to get new screens for the facility. He said due to costs, no screens had been ordered/purchased at this time. Maintenance Service Policy dated December 2009 indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for 455642 Page 11 of 12 455642 06/28/2023 Dayton Nursing and Rehabilitation 310 E Lawrence St Dayton, TX 77535

F 0921 maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 455642 Page 12 of 12