Health inspection·March 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of (Halls 500 and 600) six halls and 3 (Residents #1, #2, and #3) of 9 residents reviewed for safe environment in that, 1. The facility failed to provide hot water on Halls 500 and 600 2. The facility failed to provide linens free from stains and holes for Residents #1, #2, and #3. These failures could place residents at risk for a diminished quality of life due to an unhomelike and uncomfortable environment. Findings included: During an interview on 03/12/24 at 6:29 AM, ADON A stated she was the Unit Manager over the 500 Hall and 600 Hall which were secured units. She stated she had not received any complaints related to the facility linens or water temperatures. She stated she had seen a few towels with stains but they did not really look bad. In an observation on 03/12/24 at 7:09 AM, in room [ROOM NUMBER] which was occupied by Resident #1, the resident was out of the room, her bed was unmade, there were multiple yellow stains on the fitted sheet along the left side and middle of her bed. The largest yellow stain was along the outer edge of the sheet and appeared to be approximately 8 inches by 6 inches. There were smaller yellow stains closer to the foot of the bed. A black stain was observed near the head of the bed that was approximately 2 inches in diameter. Her pillow was observed on her nightstand, her pillowcase was observed to have large yellow stains on it. The water in her bathroom was checked, the hot water handle was used and allowed to run for 2 minutes (timed using stopwatch app on phone), the water remained cold to touch. The other handle was checked the same way and no difference in water temperature was felt . When a thermometer was used to test the temperature of the hot water, it did not rise above 60 degrees F. In an observation on 03/12/24 at 7:16 AM, in room [ROOM NUMBER]B which was occupied by Resident #2, the resident was out of the room. Her bed was made, two holes were observed in her bedspread that appeared to be approximately 2 inches in diameter. The bed was situated against the far wall in the room near a window. The holes could be seen upon entering the room. The water in her bathroom was checked, the hot water handle was used and allowed to run for 2 minutes, the water remained cold to touch. The other handle was checked the same way and no difference in water temperature was felt When Page 1 of 8 455733 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0584 the hot water was tested with a thermometer, it did not rise above 60 degrees F. Level of Harm - Minimal harm or potential for actual harm During an interview with LVN D on 03/12/24 at 7:25 AM, he stated he had worked at the facility for about a month. He stated he reported the lack of hot water in the employee bathroom about a month ago and it had since been fixed. LVN D stated he was unaware of the lack of hot water in the resident's rooms. When shown the bedspread in room [ROOM NUMBER], LVN D stated he had not noticed it before, and it was not appropriate. LVN D was then shown the stained linens in room [ROOM NUMBER] and he began stripping the bed. He stated that was inappropriate as well. He stated he was unable to tell if the linens were fresh and stained or soiled. LVN D stated having stains or holes in linens could make the residents feel bad and as though they were not important. Residents Affected - Some During another interview with ADON A on 03/12/24 at 7:30 AM, when asked whether she had ever seen stains on the residents' linens, she stated she had seen some on the towels and washcloths. When asked whether she felt those were appropriate to give to the residents, she replied, They're not super dark, more like light yellow stains. She stated the residents might not feel good about it. During an interview and observation in the shower room on the 600 hall on 03/12/24 at 7:35 AM, the hot water was checked and allowed to run for 2 minutes using each handle. The water felt cold to touch and no difference was felt using either handle. When the hot water was checked with a thermometer by this surveyor, it registered at 60 degrees. LVN D was nearby and stated he recalled reporting that around the same time as reporting the employee bathroom to ADON A about a month prior. He stated the residents were taken down the 400 Hall for showers. He stated he had not reported it again since. In an interview on 03/12/24 at 7:40 AM, CNA E stated she rotated around the building and was assisting on the secured units. She stated she was aware the 500 and 600 halls had no hot water. She stated she knew the issue had already been reported and she believed they were waiting for a part to be installed. She denied hearing complaints from residents. She stated they used other shower rooms for bathing and used wipes for cleaning the residents. CNA E stated linens with holes or stains should be bagged separately and reported to housekeeping so they could order replacements. She denied seeing any on the 600 Hall that morning. During an observation and interview on 03/12/24 at 7:45 AM, Resident #3 was observed on the 600 Hall, in her room in bed. She was resting on two pillows. The bottom pillow had no pillowcase, the top pillowcase was a dingy off-white color and had several small black spots along the left side. Resident #3 stated she had asked for new pillowcases a few days ago, mine are grungy. She was unable to recall who she spoke with. She stated the water in her bathroom had been cold for a while. She stated it was bothersome when she washed her hands or face, but showers were not a problem because she went to another hall for those. Resident #3 denied complaining to staff about the water temperature. During an interview on 03/12/24 at 8:05 AM on the 500 hall, CNA G stated she rotated shifts and halls. She stated there was no hot water on the 500 and 600 halls. She stated she was not sure how long the hot water had been out and stated, I think they are trying to fix it. She stated she had not heard any residents complain and took them to another hall for showers. CNA G stated she occasionally found linen stained. She stated she had not used stained linen on resident beds and returned any stained linen she found to the laundry department. CNA G stated she would not use stained or torn linens for the residents because it would not look or feel good to have linen looking like that. During an interview and observation on 03/12/24 at 8:13 AM, the DON was asked about the lack of hot 455733 Page 2 of 8 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some water on the secured units (500 and 600 Halls). She stated, We've had these complaints before, they're not running the water long enough. The DON was asked to demonstrate and was observed running the water in the shower room in the 600 Hall shower room. The DON was observed running the water with her hand in the stream but made no mention of the temperature The DON stated, if the staff knew the water was running cold, they should have reported it to maintenance so he could check the pilot light. The DON stated staff had been taking residents to another hall to shower as long as she had been there and she stated they preferred to use the shower room on the 400 Hall. She stated she believed they used the other shower room because it was larger and not because of the water temperature. She stated anyone could make a report to maintenance and she would look into the issue. During an interview on 03/12/24 at 8:25 AM, the Administrator stated she had just heard about the lack of hot water from the DON and was contacting maintenance. She said she was unaware there was no hot water on the secured units. She stated any staff member could contact maintenance. The Administrator stated the facility used a program called, Maintenance Care and any member of the management team could access it. She stated the employees should report any issues to their managers and they could enter the information. The Administrator stated the facility recently had plumbing work done and would pull the documentation. On 03/12/24 at 9:00 AM, attempts to interview Residents #1 and #2 was unsuccessful due to poor cognition. During a follow-up interview on 03/12/24 at 9:48 AM, the Administrator stated the water temperatures were to be checked weekly and she had believed the problems had been addressed. She stated she had been unaware there were still any issues with the water. The Administrator stated she expected worn or stained linens to be thrown out and reported to the housekeeping department. She stated she had not received any complaints related to the condition of the linens and expected the housekeeping department to monitor the condition of the linen. She stated risks included resident dissatisfaction. In an interview on 03/12/24 at 10:05 AM, the Maintenance Supervisor stated a new mixing valve had been placed in February and he had been testing the water weekly ever since. He stated the valve replacement was done to correct the hot water issues that had affected the 500 and 600 halls. He stated he last checked the temperature that morning after hearing there was a problem and found the temperature to be low. He stated he had made the necessary adjustments and the hot water was functioning again. The Maintenance Director stated he had previously informed the nursing staff of the changes and that it might require periodic adjustments. He stated he had not received any recent complaints about the water temperatures. A follow-up interview with ADON A on 03/12/24 at 10:21 AM, revealed she was aware there were previous complaints about the water temperatures and knew there had been some plumbing work done. She stated she had assumed the problem had been resolved because she had not received any further complaints. An observation on 03/12/24 at 10:30 AM, revealed the hot water had been restored within the 500 and 600 halls. In an interview on 03/12/24 at 11:23 AM, the Housekeeping Supervisor stated he occasionally found linens with stains or holes and his laundry staff tried to remove them from circulation whenever they 455733 Page 3 of 8 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some found them. He stated he expected nursing staff to bag them separately as they found them and let them know so that new linen could be ordered. The Housekeeping supervisor stated he had no issues ordering new linens when needed. He stated he did not believe the facility had a written policy related to stained or torn linens. The Housekeeping Supervisor stated maintaining linens in good condition was important for the facility because no one wanted to sleep on bad linens. He stated residents could develop skin problems from laying directly on mattresses due to holes in the linens. In an interview and record review with the Administrator and Maintenance Supervisor on 03/12/24 at 12:51 PM, the Administrator provided a Service Report dated 2/16/24 that reflected the following description of work: .Picked up material from shop and arrived on site, checked in with customer and found that the valve was positioned so that the valve could not be rebuilt easily. Left for parts to take it out and repair it, came back and made the repair and set the valve in the green zone but told the customer to keep an eye on it and adjust as needed . The Administrator provided an invoice dated 2/26/24 that reflected the valve repair. Temperature logs were also provided which reflected the water temperatures on the 500 Hall was 99 degrees F on 2/27/24 and 3/3/24. The water temperatures on the 600 Halls were 100 degrees F on 2/27/24 and 101.5 degrees on 3/3/24. The Maintenance Supervisor stated he had informed all staff working on the affected units when the repairs had been completed and had advised them to let him know if other adjustments were needed. He stated he had not received any complaints since that time. A request was made for any facility policies related to water temperatures and linens. No facility policy was provided related to water temperatures. The facility policy titles, Linens dated 2018 reflected the following: 1. Resident linens must be clean and dry and changed regularly .7. Collect and remove soiled linens immediately. Soiled linens will be transported to the laundry processing area in a covered laundry hamper 455733 Page 4 of 8 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one (Men's Secured Unit) of two (Men's Secured Unit and Women's Secured Unit) resident secured units reviewed for sufficient staff. The facility failed to have sufficient staff available to provide resident care and supervision for the men's secured unit on the 10:00PM to 6:00AM shift beginning on 03/11/24 and ending on 03/12/24. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: Observation of the Women's Secured Unit on 03/12/24 at 4:10AM revealed the two staff members who were assigned to work on the separate secured units, CNA H and LVN C, were both physically present on the Women's Secured Unit. Observation of the Men's Secured Unit on 03/12/24 at 4:15AM revealed there were no staff members present on the Men's Secured Unit. It appeared as though all the residents on the Men's Secured Unit were in their rooms; no residents were observed wandering the halls and no call lights had been activated. During an interview with LVN C on 03/12/24 at 4:10AM, she stated that she and CNA H were the only staff members who were assigned to work on the separate men and women's secured units. LVN C stated the facility was currently running short on staff. She said the facility typically staffed 2 Nurses and 5 CNAs on the 10:00PM-6:00AM shift; however, on the current shift, the facility only had 2 Nurses and 3 CNAs on duty. LVN C stated she notified the appropriate parties that there had been call-ins for the current shift, but no coverage was found. She stated because of this, at the time of the surveyors' entrance into the building, there were no staff members present on the Men's Secured Unit. LVN C said typically, she and CNA H would switch off so there was always coverage on both units, but she was busy completing documentation which kept her from being on the men's side of the secured unit. During an interview with the Administrator on 03/12/24 at 12:52PM, she stated the facility typically staffed the 10:00PM-6:00AM shift with 2 Nurses and 4-5 CNAs. She stated on the most recent 10:00PM-6:00AM shift in which the surveyors entered the facility, none of the direct care staff present advised that there was a call-in on the secured unit, leaving them short staffed. She stated she was not aware that the Men's Secured Unit was left unsupervised; the expectation was for both the men and women's secured units to be supervised at all times. She stated the risk of a secured unit being left unsupervised was the potential for accidents and negative outcomes. Review of the facility's Employee Punch Report, dated 03/12/24, revealed on the 10:00PM to 6:00AM shift (03/11/24 to 03/12/24), there were 2 Nurses and 3 CNAs who worked the shift. 455733 Page 5 of 8 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0725 During an interview with the Administrator on 03/12/24 at 2:20PM, she stated the facility did not have any written policies or procedures related to staffing levels or staffing of the secured units. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 455733 Page 6 of 8 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 4 of 5 medication carts (Halls 100, 200, 300 hall nursing carts, and Medication Aide cart) and 1 of 1 treatment cart reviewed for drug storage. LVN A left 4 medication carts and 1 treatment cart unlocked and unattended in the hallway near the 300 Hall nursing station for an unknown amount of time . These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings include: In an observation during initial tour of the facility on 03/12/24 at 4:08 AM, 4 medication carts and one treatment cart were observed lined up surrounding a corner nurses' station on the 300 Hall . No staff were observed in the area and no residents were observed in the hallways. An observation on 03/12/24 at 5:04 AM at the 300 Hall nurses' station revealed there were 4 medication carts and 1 treatment cart situated around the nurses' station. All 5 carts were unlocked. During an observation and interview on 03/12/24 at 5:26 AM at the 300 Hall nurses' station, LVN B stated he had been responsible for all the carts there during the 10:00 PM to 6:00 AM shift. He stated he was covering the 100, 200, and 300 halls that evening. The carts were used for those halls and included nurses and medication aide carts as well as a treatment cart. He stated he had counted the carts with the previous shift with no concerns. He stated he was accustomed to managing the carts overnight and typically carried one set of keys for one cart on his person and locked all the other keys into that cart. He stated the carts should be locked at all times. LVN B stated he could not explain why he had walked away leaving them all unlocked and must have become side-tracked while organizing and stocking the contents. He stated managing so many carts was not usually a problem for him but he had become busy during the night. He was unable to say how long he was away from the carts while they were unlocked. LVN B stated the risks for leaving the carts unlocked included residents could gain access to items such as medications and scissors which could cause injury or illness. In an interview on 03/12/24 at 11:47 AM, the DON stated she had been made aware by LVN B that the medication carts and treatment cart had been left unlocked and unattended that morning. She stated the carts had been checked and they found nothing to be missing. The DON stated all nursing staff were responsible for ensuring their carts were locked and secure at all times. She stated she and the ADONs had already initiated in-service training with all nurses and medication aides. The DON stated medication and treatment carts should always be locked when not in use and risks included unauthorized access to medications by residents. During an interview with the Administrator on 03/12/24 at 12:51 PM, she stated she had been made aware there were unlocked medication carts in the hallway that morning and the DON had initiated in-services. She stated all nursing staff were responsible for ensuring the medication carts were locked and secured at all times. She stated risks included unauthorized access to medications by residents. 455733 Page 7 of 8 455733 03/12/2024 Heritage at Turner Park Health & Rehab 820 Small St Grand Prairie, TX 75050

F 0761 Record review of the facility's policy and procedure titled, Medication Carts, dated 2003 reflected: Level of Harm - Minimal harm or potential for actual harm 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse . Residents Affected - Some 4. Carts must be secured 455733 Page 8 of 8