Health inspection·July 21, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 2 of 24 residents (Resident #36) reviewed for resident rights, in that: Residents #36 and #148 were told they could not flush toilet paper down the toilet of their shared bathroom and must dispose of soiled toilet paper in the receptacle. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record review of Resident #36's face sheet, dated 07/21/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of acute on chronic right heart failure. Record review of Resident #36's annual MDS, dated [DATE], revealed a BIMS of 12 which indicated moderate impairment. Record review of Resident #36's comprehensive person-centered care plan, dated 07/21/2023, reflected no indication of a limitation on paper in commode use or independence with toileting. Record review of Resident #148's face sheet, dated 07/21/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of fluid overload. Record review of Resident #148's quarterly MDS, dated [DATE] revealed a BIMS of 14 which indicated no cognitive impairment. Record review of Resident #148's comprehensive person-centered care plan, dated 07/21/2023, reflected no indication of a limitation on paper in commode use or independence with toileting. Observation and interview on 07/20/2023 at 3:01 PM, revealed the bathroom to Room B6 to be a shared bathroom with Room B5. The shared bathroom had a single commode with a sign above it which reflected, Attention: Please do not flush any material down the toilets . No wipes, no paper, thank you for your cooperation. Resident #36 stated she was informed by nursing staff to not flush toilet paper and wet wipes down the toilet as it will cause a clog in the plumbing. Resident #36 stated the sign has been up for as long as she has been in the room since at least a few months ago. Resident #36 Page 1 of 13 455676 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0550 Level of Harm - Minimal harm or potential for actual harm stated there was a plumbing leak and the toilet overflowed with toilet water into their bedroom in the last few weeks. Resident #148 stated she remembered the incident and did not know why the toilet clogged but stated she was also told by nursing to not flush anything down the toilet and instead to dispose of soiled paper in the garbage bin in the bathroom. Resident #148 and Resident #36 stated they did not remember which nursing staff told them that but that the sign had explicit instructions on not flushing paper. Residents Affected - Few Interview on 07/20/2023 at 3:41 PM, the MS stated he understood the facility's plumbing to be vulnerable to clogs but had not known of a restriction on toilet paper going into the toilets. The MS stated he had not provided any directive to nursing staff to restrict paper going into the toilets and had only had 1 toilet clog and overflow in the last several months and that that instance was in Room B6 where he repaired the commode within a few hours. The MS stated he was unaware of the sign posted in the bathroom to Room B6 and was not aware of any other bathroom containing a similar sign. Interview on 07/21/2023 at 11:11 AM, the DON stated she was not aware of toilet paper restrictions on toilets in the facility and was not aware of the posted sign in Room B6 related to the flushing of paper into the toilet. The DON stated she had not given a directive to nursing staff to instruct residents to not flush toilet paper down the toilet and to instead use the receptacle. The DON stated residents were able to flush toilet paper into the toilet and to otherwise use the receptacle would be a concern in that it had presented an infection control risk as that was a shared bathroom with soiled paper in the receptacle. The DON stated it was her expectation that staff not tell residents to dispose of toilet paper in waste bins. Interview on 07/21/2023 at 11:11 AM, the ADM stated he was not aware of toilet paper restrictions on toilets in the facility and was not aware of the posted sign in Room B6 related to the flushing of paper into the toilet. The ADM stated it was his expectation that staff not tell residents to dispose of toilet paper in waste bins. Record review of the facility policy and procedure titled, Resident Rights Guidelines for All Nursing Procedures, revision date April 2013 reflected in part, .To provide general guidelines for resident rights while caring for the resident .Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on residents rights, including: .resident dignity . 455676 Page 2 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review; it was determined the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 6 (Resident #31) residents reviewed for resident rights. Residents Affected - Few The facility failed to ensure Resident #31 had the right to receive visitors inside the facility. This failure placed residents at risk of isolation, decreased emotional well being and diminished quality of life. The findings included: Record review of Resident #31's face sheet, dated 7/20/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), pneumonia (an infection that inflames the air sacs in one or both lungs), hypertension (high blood pressure), muscle wasting and atrophy (wasting [thinning] or loss of muscle tissue), end stage renal disease and depression. Record review of Resident #31's most recent quarterly MDS assessment, dated 5/5/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #31's comprehensive care plan, revision date 5/30/23 revealed the resident had behavioral symptoms and does not follow visiting rules and has visitors outside of exceptable [sic] time frame with the goal to have behavior identified so that staff may intervene quickly. During an interview on 7/18/23 at 9:28 a.m., Resident #31 revealed his family member worked mostly nights and wanted to visit Resident #31 after work, sometimes after midnight. Resident #31 stated, I have asked why she can't visit me, I thought we were a 24-hour facility. Resident #31 revealed LVN A would come into the resident's room, doesn't knock, and will say it's almost midnight and tells his visitor she has to go. Resident #31 revealed he had not been given an explanation why his family member could not visit past midnight. Resident #31 revealed he had been informed by the facility he could only have 30 minutes to an hour for visits if the visits were after midnight. During an interview on 7/20/23 at 4:22 p.m. with Resident #31's roommate revealed it did not bother him when Resident #31's family member visited. Resident #31's roommate revealed he got along with Resident #31. During an interview on 7/20/23 at 4:37 p.m., the DON revealed, the facility did not have any restrictions on visitation as long as the resident agreed with the visitation. The DON revealed there was no time limit imposed on visits as long as the resident agreed to the visit. The DON revealed she was aware Resident #31's family member visited at odd times, like 3:00 a.m. in the morning. The DON revealed she was not aware staff had been telling Resident #31's family member she had to leave the facility when visiting late at night, and further stated, the staff do not have the right to do that. The DON stated, we don't have any visitation rules. 455676 Page 3 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0563 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview on 7/20/23 at 4:54 p.m., LVN A revealed she was scheduled to work the overnight shift from 7:00 p.m. to 7:00 a.m. LVN A stated, Resident #31's family member comes in at around 11:00 p.m. and will stay sometimes up to 4:00 a.m. LVN A stated, because all the residents are sleeping, the family member has to leave by midnight. LVN A revealed the rule did not apply to any other residents other than Resident #31. LVN A revealed she had made management aware of Resident #31's family member visiting late at night and stated, I leave it up to management since I am actually just agency. During an interview on 7/21/23 at 2:58 p.m., the Administrator revealed, the facility was a 24-hour facility, and the family can visit at any time and Resident #31's family cannot be denied visitation. Record review of the facility policy and procedure, titled Visitation, revision date February 2014 revealed in part, .Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility .1. We recognize the resident's need to maintain contact with the community in which he or she has lived or is familiar. Therefore, the resident is permitted to have visitors as he/she wishes .2. The facility provides 24-hour access to all individuals visiting with the consent of the resident . 455676 Page 4 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #44) reviewed for pharmacy services in that: The facility failed to accurately transcribe and clarify Resident #44's prescription for levofloxacin (an antibiotic) into the electronic medication administration record. This deficient practice could affect residents who received medications and place them at risk for adverse reaction and/or a decline in health. The findings included: Record review of Resident #44's face sheet, dated 7/21/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), pneumonia, dysphagia, oropharyngeal phase (difficulty swallowing occurring in the mouth and/or the throat), pneumonitis due to inhalation of food and vomit and gastrostomy status (a surgical opening into the stomach for the introduction of food; feeding tube). Record review of Resident #44's admission MDS assessment, dated 7/8/23 revealed the resident was severely cognitively impaired for daily decision-making skills and had a feeding tube. Record review of Resident #44's comprehensive care plan, created on 7/17/23 revealed the resident had a potential for dehydration related to NPO (nothing by mouth status) and tube feedings. Record review of Resident #44's current physician's orders, undated revealed the following: -levofloxacin tablet 500 mg oral once a day, 9:00 a.m., with start date 7/13/23 and end date 7/22/23 -Diet: NPO (nothing by mouth), with start date 7/1/23 and no end date Observation on 7/20/23 at 9:07 a.m. during the medication pass with LVN B revealed a medication blister packet of levofloxacin prescribed to Resident #44 with the following instructions on the pharmacy label: -levofloxacin 500 mg tablet, give 1 tablet by mouth daily for 10 days. During an interview on 7/20/23 at 9:50 a.m., LVN B revealed Resident #44 was strictly NPO and received all of the medications and nutrition via the feeding tube. LVN B revealed the pharmacy label was incorrect and the physician's orders should have been clarified for Resident #44's levofloxacin antibiotic to indicate the medication was supposed to be given via the feeding tube and not by mouth. LVN B revealed, Resident #44 could have received the medication incorrectly by mouth by staff who did not know the resident was NPO and could have caused the resident to choke or aspirate. 455676 Page 5 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/20/23 at 4:33 p.m., the DON revealed, Resident #44's levofloxacin antibiotic order should have been clarified to indicate the resident would receive the medication via a feeding tube and not by mouth. The DON revealed, if a new nurse or agency nurse was not familiar with the resident and followed the order as written, the resident could have choked or aspirated. Record review of the facility policy and procedure, titled Administering Medications, revision date December 2012 revealed in part, .Medications shall be administered in a safe and timely manner .5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . 455676 Page 6 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #98) reviewed for unnecessary medications in that: Residents Affected - Few The facility failed to address the pharmacist consultant's recommendation for the routine use of antibiotic therapy for Resident #98. This failure could place residents at risk for adverse drug reactions and receiving unnecessary medications. The findings included: Record review of Resident #98's face sheet, dated 7/21/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pneumonia, pain, acute candidiasis of vulva and vagina (yeast infection), hypertension (high blood pressure), urinary tract infection, dementia without behavioral disturbance and long-term drug therapy. Record review of Resident #98's most recent quarterly MDS assessment, dated 6/18/23 revealed the resident was moderately cognitively impaired for daily decision-making skills, was occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #98's Prescription Order, start date 5/13/23 revealed the following: -Order on hold from 6/16/23 9:00 a.m. to 6/26/23 9:00 a.m. Macrobid capsule 100 mg once a day, start date 5/13/23 and no end date. Diagnosis: Urinary tract infection, site not specified. The section for Special Instructions was blank. Record review of Resident #98's Medication Administration Record for 7/1/23 to 7/21/23 revealed the resident received Macrobid 100 mg oral once a day, diagnosis Urinary tract infection, with order date 5/13/23 and no end date. The section under Special Instructions was blank. Record review of Resident #98's Consultant Pharmacist's Medication Review, for recommendations reviewed for February 2023 revealed, This resident has an order for Macrobid, which is subject to the stop order policy. Please clarify the order to include a stop date. If it is to be used routinely, an indication for a chronic condition should be documented to support usage. A handwritten note indicated prophylaxis on the document. Record review of Resident #98's Medical Director Report for recommendations reviewed for March 2023 made by the pharmacy consultant revealed, this resident has received Macrobid 100 mg po QD for UTI prophylaxis since 1/20/23. Long term antibiotic use may not decrease incidences of UTI but may increase risk of antibiotic resistance. Please evaluate and discontinue this medication. If continued, please document risk vs benefit in your reply below. Thank you, Consultant Pharmacist. The facility did not indicate or document the risk vs benefit for Macrobid per the pharmacy consultant's recommendation. During an interview on 7/21/23 at 11:10 a.m., the DON revealed, Resident #98 had a current order 455676 Page 7 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for Macrobid antibiotic but did not currently have a urinary tract infection. The DON revealed she and the ADON were responsible for notifying the physician about pharmacy consultant recommendations, but she had only been the DON for approximately 2 ½ months. The DON revealed Resident #98's order for the use of Macrobid antibiotic therapy should have included the reason for long term use, prophylaxis, per the pharmacy consultant's recommendation. The DON revealed, Resident #98's long term use of antibiotics could result in the resident becoming immune to long term use of Macrobid and the medication would no longer fight the infection resulting in the resident being subjected to stronger antibiotic use which could cause complications. The DON revealed on 7/21/23 at 3:33 p.m., the facility did not have a policy and procedure for pharmacy consults. 455676 Page 8 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

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 observations, interviews, and record reviews, 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 #34) reviewed for infection control practices, in that: Residents Affected - Few CNA C and CNA D did not utilize appropriate hand hygiene during incontinent/catheter care to Resident #34. These failures could place residents who required incontinent/catheter care at risk for infection or a decline in health. The findings included: Record review of Resident #34's face sheet, dated 7/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral infarction (a stroke, a disrupted blood flow to the brain due to problems with the blood vessels that supply it), enterocolitis (inflammation of the colon) due to clostridium difficile (a bacteria that causes diarrhea), urinary tract infection, pain and heart failure. Record review of Resident #34's most recent quarterly MDS assessment, dated 6/23/23 revealed the resident was severely cognitively impaired for daily decision-making skills and had an indwelling urinary catheter. Record review of Resident #34's comprehensive care plan, dated 7/16/23 revealed the resident had a urinary tract infection related to indwelling urinary catheter with interventions that included to keep perineal area clean and dry and perform catheter care daily. Record review of Resident #34's current physician's orders, undated revealed the order for catheter care every shift, twice a day, with order date 4/6/23 and no end date. Observation on 7/20/23 at 1:03 p.m., during incontinent/catheter care to Resident #34 revealed CNA C removed her gloves after providing catheter care to Resident #34, did not utilize appropriate hand hygiene and put on a new pair of gloves. CNA C then took Resident #34's indwelling catheter bag from the left side of the resident's bed and gave it to CNA D on the right side of the bed. CNA C and CNA D then assisted Resident #34 onto his right side and CNA C continued with incontinent care. CNA C, after cleaning Resident #34's rectal area and buttocks, removed her gloves, did not utilize appropriate hand hygiene and put on a new pair of gloves. CNA C then took a clean incontinent brief, placed it on the resident's bed and both CNA C and CNA D assisted Resident #34 onto his back. After incontinent/catheter care was completed, CNA C and CNA D removed their gloves, did not utilize appropriate hand hygiene and CNA C took the bed remote to adjust Resident #34's bed. CNA C and CNA D then took the draw sheet from underneath the resident and pulled the resident up in bed. During an interview on 7/20/23 at 1:19 p.m., CNA C revealed she had not utilized appropriate hand hygiene between gloves changes because she and CNA B could not find a bottle of hand sanitizer. CNA C revealed she was supposed to use the wall mounted sanitizer, but it was across the room. CNA C revealed, not utilizing appropriate hand hygiene resulted in cross contamination and it would be an 455676 Page 9 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection control issue. CNA C revealed, cross contamination could make the resident sick, such as developing a bacterial infection such as a urinary tract infection and the infection could be spread to herself and others. During an interview on 7/20/23 at 1:19 p.m., CNA D revealed she had not utilized appropriate hand hygiene between gloves changes because she and CNA C had forgotten the bottle of hand sanitizer. CNA D revealed she had been trained on infection control, including hand hygiene at least annually and last received training about a month ago. During an interview on 7/20/23 at 4:52 p.m., the DON revealed best nursing practice during incontinent/catheter care was to utilize appropriate hand hygiene between glove changes to avoid cross contamination. The DON revealed it was her expectation for staff to perform hand hygiene between glove changes because the gloves were dirty and when removed could be tainted. The DON revealed, cross contamination was infection control issue and could result in the resident developing an infection and the infection could spread to the staff. Record review of CNA C's Handwashing Skills Checklist competency dated 5/23/23 revealed CNA C had satisfied the requirements for utilizing appropriate hand hygiene skills. Record review of CNA D's Handwashing Skills Checklist competency dated 5/24/23 revealed CNA D had satisfied the requirements for utilizing appropriate hand hygiene skills. Record review of the facility policy and procedure titled, Handwashing/Hand Hygiene, Revision date August 2015 revealed in part, .This facility considers hand hygiene the primary means to prevent the spread of infections .3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations .b. Before and after direct contact with residents .Before donning sterile gloves .Before handling clean or soiled dressings .After contact with a resident's intact skin .after contact with objects .in the immediate vicinity of the resident .After removing gloves . 455676 Page 10 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, record review, and interview, the facility failed to ensure that 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) provided a minimum of 80 square (sq.) feet (ft.) per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms. The findings were: Observation on 07/19/2023 at 10:00 a.m. and measurement of rooms designated for three residents revealed room #A5 measured 217 sq. ft. (72.3 sq. ft. per resident) with one resident residing in the room, room #A6 measured 220.5 sq. ft. (73.6 sq. ft. per resident) with no residents residing in the room, room #A9 measured 228 sq. ft. (76.0 sq. ft. per resident) with two residents residing in the room, and room #A11 measured 225 sq. ft.(75.0 sq. ft. per resident) with one resident residing in the room. Observation of resident room # A11 revealed it had 2 light fixtures and 2 call light systems visible. Interview with the Administrator on 07/21/2023 at 1:30 p.m. confirmed that four of the facility's room were below 81 square feet required per resident. The rooms were #A5, #A6, #A9, and #A11, and he wanted to continue the room waivers for these rooms. Record Review of the Bed Classification Form, dated 07/20/2023, revealed resident rooms #A5, #A6, #A9, and #A11 were certified as rooms for 3 residents per room. 455676 Page 11 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program for 1 of 28 rooms and 1 and 1 kitchen reviewed for pests, in that: Residents Affected - Many The facility failed to ensure the pest control program was effective in all areas of the facility. 1. Freezer 2 had one, live, three-centimeter roach and one, live, one-centimeter ant crawling inside the lower compartment. 2. Fridge 3 had two, live, one-centimeter ants crawling inside the lower compartment of the unit. 3. Fridge 2 had two, unmoving, one-centimeter ants inside the lower compartment of the unit. 4. room [ROOM NUMBER] had a live four-inch roach crawling along the wall. This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections. The findings included: Observation and interview on 07/19/2023 at 3:22 PM, revealed a single three-centimeter roach and a single one-centimeter ant crawling inside Freezer 2. The DM stated That's a roach and an ant when asked to identify the moving pests. Within Fridge 3, there were two one-centimeter ants crawling around the lower compartment. Within Fridge 2, two one-centimeter ants that were immobile in the lower compartment. The DM stated to the two one-centimeter ants in the refrigerator were unknown and was unable to identify them. The DM stated she had not seen pests within the kitchen reach-in fridges or freezers before today and stated her expected protocol was to report the pest sighting to her MS in the maintenance work order book at the nurse's station. Interview on 07/19/2023 at 3:49 PM, the MS stated he began operating as the facility MS since February of 2023 and since then, he had not received complaints from residents related to pests or received work orders within the work order books related to pest sightings. The MS stated the expected protocol for any staff upon suspecting the existence of pests would be to complete a work order form in the work order books found at the nurse's station. The MS stated he had the pest control vendor visit the facility every three-months and the last visit was in the last few weeks. Interview on 07/21/2023 at 11:01 AM, the DON stated she was not aware of the existence of pests in the facility and expected staff to report pest sightings in the work order books at the nurse stations. The DON stated it was her expectation that pests not be allowed to enter the food storage units intended for residents as that could create a risk for illness. Interview on 07/21/2023 at 3:14 PM, the ADM said he was not aware of the existence of pests in the facility and it was his expectation that staff complete a work order request for pest sightings in the work order books. The ADM stated it was his expectation that pests not be within the food storage as that had a risk of causing illness. Record review of Work Order Book 1 reflected no requested work orders related to pests from 455676 Page 12 of 13 455676 07/21/2023 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0925 02/01/2023 and 07/21/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Work Order Book 2 reflected no requested work orders related to pests from 02/01/2023 and 07/21/2023. Residents Affected - Many Record review of the Pest Control Policy, titled Pest Control, dated May 2008, reflected Our facility shall maintain an effective pest control program . This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Record review of the undated facility contract with [Commercial Pest Control Company] revealed they were contracted for pest control services with routine visits every three months. Record review of the facility pest control visits reflected a routine visit occurred on 06/03/2023 without specific indications of pests in the facility. 455676 Page 13 of 13