Health inspection·December 14, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 2 Common Baths (Pod A (SB) and Pod B (JH)) and 9 of 25 resident rooms (room [ROOM NUMBER]SB, 110SB, 111SB, 217SB, 218SB, 220SB, 108JH, 218JH and 326JH) reviewed. The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 113 to 118.8 F, and The facility failed to ensure bathing and restroom area grab bars were securely attached to the walls. This failure could place residents at risk for injuries related to non-secure grab bars and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water. The findings included: Observation on 12/13/23 at 1:08 PM the common bath on the A Pod (SB) unit hand sink had hot water at 114.3°F. Observation on 12/13/23 at 1:25 PM in room [ROOM NUMBER]SB, the hot water was 118.8°F at the hand sink and it was witnessed by CNA D. Observation on 12/13/23 at 1:30 PM in room [ROOM NUMBER]SB the hot water at the hand sink was 117.7°F. Observation on 12/13/23 at 1:37 PM in room [ROOM NUMBER]SB, the hot water at the hand sink was 116.6°F and the grab bar was loose in the restroom. Observation on 12/13/23 at 1:40 PM room [ROOM NUMBER]SB had one of two grab bars loose in the shower and the hot water was 115.3°F at the hand sink. Observation on 12/13/23 at 1:44 PM in room [ROOM NUMBER]SB, one of three grab bars was loose in the shower stall. The hot water was 114.8°F at the hand sink. Observation on 12/13/23 in room [ROOM NUMBER]SB at 1:50 PM, 1 of 2 grab bars was loose in the Page 1 of 24 455771 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0689 shower stall and the hot water was 113.2°F at the hand sink. Level of Harm - Minimal harm or potential for actual harm Observation on 12/13/23 at 1:54 PM the B pod common bath (JH) had one of two shower stalls (#1) had one of three bars that was loose. The hot water at the hand sink was 114.4°F. Residents Affected - Some Observation on 12/13/23 at 1:59 PM in the B pod area in room [ROOM NUMBER]JH the hot water at the hand sink was 114.1°F. Observation on 12/13/23 at 2:02PM in the B pod room [ROOM NUMBER]JH the hot water at the hand sink was 113.1°F. Observation on 12/13/23 at 2:04 PM in the B pod room [ROOM NUMBER]JH the hot water at the hand sink was 114.1°F. On 12/13/23 at 2:27 PM interview and observations of the boiler room were made with the Maintenance Supervisor. He stated that he tried to keep the hot water temperature between 105 degrees F and 111 to 112°F. He stated that he started his employment at the facility in September 2023. An observation was made in the boiler room revealed that the Domestic Water (resident use) temperature gauge read 123°F. The kitchen water temperature gauge read 105°F. He stated that the domestic water boiler was set at 120 F (domestic) and the other at 115 F (kitchen). Two boilers were attached to the domestic water system. Observation of the signage on the Domestic Water holding tank stated the following, 120°F Domestic Water. The Maintenance Supervisor stated, he just tested rooms 110SB and 220SB and had readings of 112° F and 115°F. He stated on a weekly basis he checked the water temperatures on the SB (Pod A) unit, Memory Care, and checked two rooms on each pod. He added, he did the same on the other pod (JH - Pod B) and then he checked the kitchen water and showers. He stated, the facility had a problem with the boilers, but it was repaired today (12/13/23). He stated that the times that he checked the water temperature were at different times of the day; morning, afternoon, and late afternoon. Observation of the mixing valve adjustment dial for the domestic water revealed that it was set slightly below the maximum heat setting mark. He stated, he heard 115°F was the maximum temperature allowed for resident use hot water and it is checked to keep it constant at 115° F. He stated that he last checked water temperatures last week. He stated he was responsible for ensuring that the water temperatures were appropriate in the facility and safe. He added that was why he checked water temperatures every week. He stated if the water was too hot residents, could get scolded. On 12/14/23 at 9:54 AM an interview was conducted with the Maintenance Supervisor, and he stated that he had not conducted any monitoring of grab bars, and he depended on the caregivers to tell him if there were repairs needed. He added, I don't check them. He stated over time, with use, they get loose. He stated he was responsible for ensuring that the grab bars were secure. He stated if there were loose grab bars, there was a chance of them coming off the wall, and a resident falling. He added it could make residents afraid to use the grab bars. He stated he retested the hot water today (12/14/23) and it was 112°F. now. Regarding why the hot water temperature was elevated, he stated now all the boilers were working; they may have needed adjusting. He added the problem may have been the extra boiler. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding the hot water and grab bars, she stated the Maintenance Supervisor now planned to have the grab bars checked on a regular basis, possibly with housekeeping assistance. She stated, the facility had the boiler serviced and most of the conversations had dealt with the water 455771 Page 2 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0689 Level of Harm - Minimal harm or potential for actual harm temperatures being cold. She added the Maintenance Supervisor was new, and he was more used to working in assisted living facilities where the water temperatures were allowed higher. She stated that the person responsible for maintaining water temperatures at a safe level was the Maintenance Supervisor. She stated that elevated hot water temperatures and loose grab bars could be a safety concern and result in potential harm. Residents Affected - Some On 12/14/23 at 2:07 PM an interview was conducted with the Administrator regarding policies. She stated, the facility went by State regulations. She added, the facility had no policy regarding hot water temperatures and maintenance grab bar issues. Record review of the facility boiler repair vendor invoice dated 12/13/23 revealed the following documentation .All boilers are down. 12/1/23 Started troubleshooting three boilers. 12/2/23 . Two other boilers for domestic use set at 120°F. Work Performed. replaced flex coupling on both boilers for domestic water and flow switch on boiler close to storage tank. Record review of the facility Logbook Documentation for monitoring water temperatures revealed between 12/9/23 and 11/3/23, temperatures were taken of resident use hot water on an approximately weekly basis. Three of six test week results revealed hot water temperatures were not reliably maintained in a comfortable range. There were six weeks of temperatures taken during this period and it was documented that the week of 11/25/23 and the week of 11/17/23, the hot water temperatures taken in both A (SB) and B (JH) pods range from 110°F to 115°F. On 11/25/23 temperatures were documented between 100°F and 114°F. During the testing on 11/17/23, the hot water temperatures ranged from 112°F to 115°F. There were no times documented as to when these temperatures were taken. It was also documented that the water temperatures on 12/1/23 on both pods ranged from 89°F to 93°F. The documentation for 12/01/23 revealed the following, Comments: issues with boilers not staying on to heat water. Boiler tech came to restart boilers after these temps were taken. Further record review of the water temperatures taken on 12/9/23 revealed that the temperature range was 102°F to 105°F. Review of the current undated American Burn Association Scald Injury Prevention Educator's Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100-degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third-degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third-degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 455771 Page 3 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0689 5 seconds. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 455771 Page 4 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 Provide enough food/fluids to maintain a resident's health. 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 offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 4 of 4 residents (Residents #2, 7, 22, and 39). Residents Affected - Some The facility failed to provide Residents #2, 7, 22, and 39 with their physician ordered therapeutic diets that included fortified foods, Cardiac diet, and 2GM Sodium for the noon and evening meals on 12/12/23 and the noon meal on 12/13/23. This failure could place residents at risk for hunger, weight loss, and chemical imbalances. The findings included: Resident #2 Record review of the current care plan dated 12/13/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Repeated Falls, Dysphagia- Oral Phase (swallowing disorder) and Moderate Protein-Calorie Malnutrition (malnutrition). Record review of the Significant Change MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of two indicating severe cognitive impairment. Further record review revealed the resident had no documented oral, dental, or swallowing issues. The resident had an active diagnosis of malnutrition. There was no documented weight loss or gain. Record review of the current undated care plan for Resident #2 revealed a Problem of (Resident #2) is at risk for alteration in nutrition related to impaired cognition/disease process dementia, disease process GERD, dysphagia, low BMI, dietary restrictions Date Initiated: 02/09/2022. Revision on: 12/15/2022. Interventions listed were, . House Supplement 2.0 four times a day Give 120mL four times a day between meals Date Initiated: 12/15/2022. Ice cream TID // fortified foods TID Date Initiated: 12/15/2022 . Provide and serve diet as ordered. Monitor intake and record every meal. Receives Regular diet Dysphagia Puree texture, Regular consistency Date Initiated: 12/15/2022. Revision on: 12/15/2022 . Record review of the Nutritional Risk Assessment V2 for Resident #2 dated 9/18/23 revealed the following, .C. Identification of Risk Indicators. 1. Rate of unplanned Weight Gain/Loss. stable . 2. Current Food and Fluid Intake. 25-100%, variable dependence at meals. 3. Relevant Labs. no new labs . 6. Chewing/Swallowing Difficulties . on puree - dysphagia noted . 8. Current Diet Orders .reg/puree/reg . D. Estimated Needs .5. Nutrition summary and interventions for plan of care: Resident annual assessment. BMI 16 - underweight. Resident on hospice - some decline in weight/appetite may be unavoidable due to progression. Resident likely not meeting estimated needs with oral intake at this time and underweight. Recommend continue to offer and encourage oral intake as appropriate. Goal to maintain resident comfort and honor goals of care while on hospice. RD to continue to monitor and follow up as needed . Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Regular diet Pureed texture, Regular consistency, Ice cream TID (3 times a day) // 455771 Page 5 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 fortified foods TID, Active 01/18/2023 . Level of Harm - Minimal harm or potential for actual harm Record review of the tray card for Resident #2 dated 12/12/23 (lunch - day 3) revealed that the resident was documented as being on a regular purée diet with foods listed as: Puréed beef enchilada with chili sauce, puréed cilantro lime rice, puréed charro beans. Notes: ice cream; fortified foods . Residents Affected - Some Observation on 12/12/23 at 11:44 AM Resident #2 was served a purée diet and it was also noted that the beans were flat on the plate. The puréed beans were a #8 scoop, puréed rice was a #10 scoop, puréed enchiladas were a #10 scoop, and they had a course or chunky appearance. No foods were identified as fortified. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the probable reason for Resident #2's diet was due to swallowing issues and to maintain weight. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Resident #7 Record review of the current care plan dated 12/13/23 for male Resident #7 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Lymphedema, Not Elsewhere Classified (fluid buildup in lymph system), Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing (Femur Fracture), Weakness, and Age-Related Physical Debility. Record review of the admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 12 indicating he was moderately cognitively impaired. Further record review revealed the resident was on a therapeutic diet. The resident had an active diagnosis of a hip fracture. Record review of the current undated care plan for Resident #7 revealed no specific care plan related to nutrition or diet. There was a Problem addressed that stated, .The resident has potential to skin integrity of the related to impaired mobility. Date Initiated: 10/04/2023. An Intervention listed was documented as, .Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 10/04/2023 . Record review of the Weight Summary for Resident #7 revealed he sustained 11.8% weight loss in 1 month from 10/04/23 he was at 309.6 lbs to 11/16/23 with the weight of 273 lbs. On 12/05/23 he gained 2 pounds up to 275 lbs. Record review of the Nutritional Risk Assessment V2 for Resident #7 dated 10/27/23 revealed the following, .5. Pressure Injury . 4) Unstageable 5. Nutrition summary and interventions for plan of care: Resident admitted post-surgery for hip fracture. Resident has unstageable breakdown to coccyx. He states that he has lost a lot of weight in past 6-8 months He states he has been eating very sparingly. PO intake potentially inadequate due to skin breakdown/increased needs. Recommend Fortified Meal Plan be added to increase kcal (calories) & pro (protein) intake. Goal healing of skin, stable wt . Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of No Salt on Tray (NSOT) diet Regular texture, Regular consistency, fortified meal plan at all meals for Nutrition, Active 10/27/2023 . 455771 Page 6 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the tray card for Resident #7 for 12/12/23 (lunch - day three) revealed the resident was on a regular, 2 g sodium diet. The menu listed, beef enchilada with chili sauce, cilantro lime rice, Charro beans . Notes: fortified foods . Observation on 12/12/23 at 11:38 AM, Resident #7 was served #8 scoop of beans, #8 scoop of enchiladas, #8 scoop of rice, and a regular cinnamon apple dessert. No foods were identified as fortified. Review of the tray card for Resident #7, dated 12/12/23 (supper - day three) revealed the resident was on a regular 2 g sodium diet. The menu listed: cream of tomato soup, grilled cheese sandwich, marinated vegetable salad. Notes: fortified foods. Observation on 12/12/23 at 4:32 PM, Resident #7 was served a grilled cheese, mixed vegetable salad, and regular tomato soup. No foods were identified as fortified. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the reason for Resident #7's diet was the resident was possibly at risk for weight loss. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Resident #22 Record review of the current care plan dated for female Resident #22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Unspecified Protein-Calorie Malnutrition (Malnutrition), Heart Failure, Unspecified, Encounter for Palliative Care, Essential (Primary) Hypertension (high blood pressure), and Pressure Ulcer of Sacral Region, Stage 3 (pressure ulcer - tissue injury). Record review of the annual MDS assessment for Resident #22 dated 11/22/23 revealed that the resident had a BIMS score of 13 indicating the resident was cognitively intact. The resident had documented active diagnoses of hypertension, malnutrition, and heart failure. There was no documented weight loss or weight gain. Record review of the current undated care plan for Resident #22 revealed a Problem of the resident has cardiac disease related to Heart Failure. Date Initiated: 08/26/2023. Revision on: 09/24/2023. No interventions were listed related to nutrition or diet. There was an intervention listed related to a care plan for the resident's diabetes mellitus that stated, .Encourage . compliance with dietary restrictions .Date Initiated: 09/24/2023 . Record review of the Nutritional Risk Assessment V2 for Resident #22 dated 9/18/23 revealed the following, C. Identification of Risk Indicators. 1. Rate of unplanned Weight Gain/Loss. -4% (loss) in 30 days, +11% (gain) in 90 days, stable in 180 (days), diuretic .8. Current Diet Orders. 2g NA/mech soft/reg .5. Nutrition summary and interventions for plan of care: Resident readmit after hospitalization for sepsis pneumonia (infection). Edema noted 09/14. Diuretic (water pill) noted - fluid shifts may impact weight trends Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of 2g Na Diet, diet Mechanical Soft texture, Regular consistency, for Heart Failure, Active 08/25/2023 . The diet was updated 12/12/23 at 12:27 PM to 2g Na Diet Regular texture, Regular consistency, for diet please include broth with each meal . 455771 Page 7 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the tray card for Resident #22 dated 12/12/23 (lunch-day 3) revealed the resident was on a regular, 2 g sodium diet with menu foods listed as: chop beef enchilada with chili sauce, cilantro lime rice with salsa, Charro beans. Note: need assistance with meals. Observation on 12/12/23 at 11:55 AM revealed Resident #22, who was on a 2 g sodium diet, received a #8 scoop of rice, #8 scoop of beans, and a #8 scoop of enchiladas. No defined 2gm sodium menu foods. Record review of their tray card for Resident #22dated 12/12/23 (supper-day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: Cream of tomato soup, grilled cheese sandwich, soft cooked broccoli. Notes: needs assistant with meals . Observation on 12/12/23 at 4:44 PM revealed Resident #22 received broccoli, regular tomato soup, grilled cheese sandwich, and a brownie. The resident did not receive any broth. No identified 2gm sodium menu foods. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the reason for Resident #22's diet could be for sodium reduction due to blood pressure and cardiac issues. She added the broth could be for an upset stomach. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Resident #39 Record review of the current care plan dated for female Resident #39 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Alzheimer's Disease, Unspecified(dementia), Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris (heart disease), Presence of Cardiac Pacemaker (heart rhythm regulating device), and Unspecified Protein-Calorie Malnutrition (Malnutrition). Record review of the quarterly MDS assessment for Resident #39 dated 11/3/23 revealed that the resident had a BIMS score of 6 indicating that she had severe cognitive impairment. Active diagnosis listed was Alzheimer's disease, coronary artery disease, hypertension, and malnutrition. There was no documentation of known weight loss or weight gain. Record review of the current undated care plan for Resident #39 revealed a Problem of The resident has potential nutritional problem. r/t poor intake and impaired cognition as evidence by diagnosis of protein calories malnutrition Date Initiated: 04/24/2023. Revision on: 05/24/2023. Interventions listed were, Provide and serve diet as ordered. Date Initiated: 05/24/2023. Provide and serve supplements as ordered. Date Initiated: 05/24/2023. Revision on: 05/24/2023. Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 05/24/2023 . Record review of the Nutritional Risk Assessment V2 for Resident #39 dated 4/22/23 revealed the following, 8. Current Diet Orders. cardiac, reg, thin liquids . 5. Nutrition summary and interventions for plan of care: Resident recently admitted . Able to feed self primarily, varied intake of meals Record review of the Weight summary for Resident #39 revealed her weight was stable at 171lbs. Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Cardiac diet Regular texture, Regular consistency. Active 04/11/2023 . ensure or 455771 Page 8 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 boost supplement with each meal with meals for malnutrition, Active 05/04/2023 . Level of Harm - Minimal harm or potential for actual harm Record review of the tray card for Resident #39 dated 12/12/23 (lunch - day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: beef enchilada with chili sauce, cilantro lime rice, Charro beans. Notes: house shake. Residents Affected - Some Observation on 12/12/23 at 11:34 AM revealed Resident #39 was served a #8 scoop of rice, #8 scoop of regular beans, #8 scoop of enchiladas, and a cinnamon apple dessert. No health shakes were observed served. Review of the tray card for Resident #39, dated 12/12/23 (supper - day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: cream of tomato soup, grilled cheese sandwich, marinated vegetable salad. Notes: house shake. Observation on 12/12/23 at 4:31 PM revealed Resident #39 was served regular tomato soup, mixed vegetable salad, and a grilled cheese. No health shakes were observed served. On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the probable reason for Resident #39's diet was due to her increased walking activity as a dementia resident and needing additional calories from a supplemental drink. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. Observation on 12/12/23 at 11:20 AM revealed Dietary staff A served and took temperatures of the noon meal foods on the service line. No foods were identified as fortified. No health shakes were observed served during the meal. On 12/12/23 at 4:15 PM a kitchen observation and interview were conducted. Observation of the service line at this time revealed temperatures were taken, and foods were served by Dietary staff D on the steam table. No foods were identified as fortified. No health shakes were observed served during the meal. On 12/12/23 at 4:47 PM an interview was conducted with Dietary staff D regarding what she used to make the foods she served. She stated: Mixed vegetable salad included vegetable blend and Italian dressing. Tomato soup was canned regular Tomato Soup. Record review of the Diet Spreadsheet, Menu . Week 1, Day: 3 - Tuesday lunch and supper revealed that there was no menu guidance listed for Cardiac diets and 2gm Na (sodium) diets. Further documentation on the Diet Spreadsheet for Week 1 Day: 3 Tuesday revealed the following, Fortified enhanced foods: follow the consistency diet ordered and offer a minimum of one fortified food item per meal, unless otherwise directed. On 12/13/23 at 3:35 PM an interview was conducted with Dietary staff A regarding fortified foods for the meals she prepared. She stated, I think pudding is just fortified. She identified no other food options as being fortified. 455771 Page 9 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/13/23 at 3:36 PM an interview was conducted with the Dietary Manager regarding therapeutic diets. He stated mashed potatoes were fortified usually. He added Dietary staff A did not make fortified foods for the noon meal on 12/12/23. He stated the fortified tomato soup was made with milk on the evening meal of 12/12/23. He stated there was a small amount of fortified mashed potatoes in a bin for the noon meal on 12/13/23. He stated, the facility ran out of shakes yesterday (12/12/23) at the noon and evening meal and none were served. He added he thought someone was taking the shakes. He also stated he did not know that Resident #22 needed broth with her meal. He stated there were issues with diet communication and at times he was not made aware of resident dietary changes in a timely manner from nursing. He further stated that the tray card and diet software had a limited amount of options regarding orders. He added that the Cardiac diet is 2 gm sodium or no added salt diet. He stated he had no other choices in the dietary department software that documents orders. He stated, regarding guidance for a 2gm sodium diet, that everything he had was low sodium and all my seasonings are low sodium. He further stated, regarding diets in the dietary software, that the diets on the menus listed were what he had, and he had no other options to match the physician orders. On 12/14/23 at 9:56 AM an interview and observation were conducted with the Dietary Manager regarding issues in the dietary department. Observation of the pantry revealed that [NAME] Tomato Soup was present. The label on the [NAME] Tomato Soup stated that it was made with tomato purée, seasonings, wheat flour, and no milk products. There was no Cream of Tomato soup. Regarding the 2 gm sodium diet, the Dietary Manager stated most foods and ingredients they used was low sodium. He stated he used direct monitoring of staff to ensure that therapeutic diets were served correctly. He stated he and staff were responsible for ensuring that therapeutic diets were served correctly. He stated residents could experience heart complications, weight loss which could lead to death and malnutrition if therapeutic diets were not served correctly as ordered. He added, he tried to avoid canned vegetables to reduce the sodium. Regarding how staff knew what a 2 gm sodium diet consisted of, he stated in-services. He further stated he was unsure of the last in-service on 2 gm sodium. He stated it had been a long time. He stated, Resident #22 wanted broth because the facility lost her teeth, and she could not eat other food. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding therapeutic diet, she stated the issues occurred due to poor planning. She added, the facility had three cases of shakes on Friday, and she found out later there were no shakes available and she got some. She stated she told the Dietary Manager to take action and follow up. She stated that the Dietary Manager was responsible for ensuring therapeutic diets were served correctly. She added residents could experience weight loss and their nutrition could be affected if they did not receive their therapeutic diet. On 12/14/23 at 1:30 PM an interview was conducted with the Dietary Manager. He stated, the facility had no specific guidance for a Cardiac Diet. He added, We only have the choices in the system (computer). He stated the diet options included Food forms - regular, mechanical soft, and purées. Diets are regular, mechanical soft, purée, low concentrated sugar, small portion and large portion. Record review of the facility's, Diet Roster - By Texture dated 12/12/23 revealed the following documentation: Resident #2 - Regular (diet), purée (texture) diet. Resident #7 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet. 455771 Page 10 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 Resident #22 - Regular (diet), 2 gm sodium (diet other), mechanical soft (texture) diet Level of Harm - Minimal harm or potential for actual harm Resident #39 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet Residents Affected - Some Record review of the facility presented Recipe Listing, Corporate Recipes for the Category of fortified foods revealed that the facility had recipes for 9 fortified foods which included, fortified cereal, fortified milk, fortified milkshake, fortified potatoes mashed, fortified pudding parfait, fortified fruit smoothie, fortified creamed soup, fortified streusel topping, and Vanilla mighty shakes. Record review of the recipe for Fortified Soup, Creamed, (assorted), Corporate Recipe - Number: 1823 revealed that the ingredients for fortified soup, consisted of assorted creamed soup, nonfat powdered milk, and bulk sour cream. Further documentation revealed the following, Notes: .2. For puréed: measure out desired number of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thicker if product needs thickening. Record review of the facility recipe titled Cream of Tomato Soup, Recipe Number: 179757 revealed that the cream of tomato soup should have included the following ingredients: water, chicken base, tomato juice, chopped garlic, dried basil leaves, ground oregano, margarine, solids and milk, and parsley flakes dried. Record review of the facility's recipe titled Puréed Cream of Tomato Soup, Recipe Number: 170386 revealed that the ingredients consisted of cream of tomato soup. Further documentation revealed the following, .Note . 2. If product needs thinning, gradually add an appropriate amount of liquid. to achieve a smooth, pudding, or soft mashed potato consistency. 3. If the product needs thickening, gradually add a commercial or natural food thicker. To achieve a smooth pudding or soft mashed potato consistency . Review of the facility policy titled, Nutrition and Foodservice Policies and Procedures Manual, 2018, Section 1-3, Policy: Menu Planning. Policy Number: 01.002, Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that nutrition is an important part of maintaining the well-being and health of its residents, and is committed to providing a menu that is well balanced, nutritious and meets the preferences of the resident population. A standardize menu which meets the nutritional recommendations of the residents, in accordance with the recommended dietary allowances of the Food and Nutrition Board of The National Research Council, National Academy of Sciences will be used. Modifications for resident population and preferences may be made as appropriate. Procedure: 1. Menus will be prepared for each facility by their food vendor. Menus are updated twice each year with the Spring - Summer and Fall - Winter cycles and updated intermittently based on resident preferences. The menus will be for a five-week cycle and will include a week at a glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide . Record review of the Long-Term Care Diet Manual, 2017 Edition, revealed the following documentation, 2 g Sodium Diet. Indications for use: the 2 g sodium diet is provided for individuals needing a significant reduction in sodium to control blood pressure and/or fluid retention for the treatment of hypertension, chronic or congestive heart failure, renal failure, or other conditions where fluid retention is a problem . General Principles and Guidelines: 455771 Page 11 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0692 1. The 2 g sodium diet is planned using the menu components as outline in Section 2: Guidelines For Menu Planning. Level of Harm - Minimal harm or potential for actual harm 2. The 2 g sodium diet is planned to provide 2000-2300 mg of sodium per day. Residents Affected - Some 3. The 2 g sodium diet does not use salt at the table or on meal trays. 4. The 2 g sodium diet limits the use of very high sodium foods to the limit of 2000 mg to 2300 mg per day. 5. Recipes should be followed carefully when cooking . 455771 Page 12 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and puree) for 4 residents (Residents #2, 7, 22 and 25) reviewed during mealtime. The facility failed to ensure Residents #2, 7, 22, and 25 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger. The findings included: Resident #2: Record review of the current care plan dated 12/13/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Repeated Falls, Dysphagia, Oral Phase (swallowing disorder) and Moderate Protein-Calorie Malnutrition (malnutrition). Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Regular diet Pureed texture, Regular consistency, Ice cream TID // fortified foods TID, Active 01/18/2023 . Resident #7: Record review of the current care plan dated 12/13/23 for male Resident #7 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Lymphedema, Not Elsewhere Classified (fluid buildup in lymph system), Displaced Intertrochanteric Fracture Of Right Femur, Subsequent Encounter For Closed Fracture With Routine Healing (Femur Fracture), Weakness, and Age-Related Physical Debility. Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of No Salt on Tray (NSOT) diet Regular texture, Regular consistency, fortified meal plan at all meals for Nutrition, Active 10/27/2023 . Resident #22: Record review of the current care plan dated for female Resident #22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Unspecified Protein-Calorie Malnutrition (Malnutrition), Heart Failure, Unspecified, Encounter for Palliative Care, and Pressure Ulcer Of Sacral Region, Stage 3 (pressure ulcer - tissue injury). Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of 2g Na Diet, Mechanical Soft texture, Regular consistency, for Heart Failure, Active 08/25/2023 . 455771 Page 13 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0803 Resident #25: Level of Harm - Minimal harm or potential for actual harm Record review of the current care plan dated for female Resident #25 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Encephalopathy, Unspecified (change in brain function), Anorexia (eating disorder), Unspecified Severe Protein-Calorie Malnutrition (Malnutrition), Weakness, Acute Kidney Failure, Unspecified, Dysphagia, Unspecified (Swallowing Disorder), Pain, Unspecified, and Pressure Ulcer of Sacral Region, Stage 4 (pressure ulcer - tissue injury). Residents Affected - Some Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Puree diet Pureed texture, Regular consistency, Active 11/07/2023 . - The following observations were made during a kitchen tour on 12/12/23 that began at 10:45 AM and concluded at 12:33 PM: An observation was made of the service line of the following foods at 11:20 AM: Beef enchiladas (premade in individual rolls) served with a #8 scoop. Rice served with the #8 scoop (1/2 cup). Refried beans serve with a #8 scoop (1/2 cup). Puréed beans serve with a #8 scoop (1/2 cup). Puréed enchiladas served with a #10 scoop (3/8 cup). Puréed rice served with a #10 scoop (3/8 cup). Dietary staff A served the meal. These foods were served one scoop each. Observation on 12/12/23 at 11:38 AM revealed Resident #7 was served #8 scoop of beans, #8 scoop of beef enchiladas, and #8 scoop of rice. The resident should have received Beef enchiladas with chili sauce 2 each + 4 ounces sauce . for his regular texture diet. It was unknown if the #8 scoop of enchilada equated to 2 enchiladas with 4 ounces of sauce. Observation on 12/12/23 at 11:39 AM revealed Resident #25 was served a #8 scoop of puréed beans, #10 scoop of puréed rice, and a #10 scoop of puréed enchilada. The resident should have received Puréed beef and enchilada with chili sauce #6 dip (2/3 cup scoop) . for her pureed texture diet. Observation on 12/12/23 at 11:44 AM revealed Resident #2 was served a #8 scoop of pureed beans, #10 scoop puréed rice, and #10 scoop puréed beef enchiladas. The resident should have received Puréed beef and enchilada with chili sauce #6 dip (2/3 cup scoop) . for her pureed texture diet. Observation on 12/12/23 at 11:55 AM revealed Resident #22 was served a #8 scoop of rice, #8 scoop of beans, and a #8 scoop of beef enchiladas. The resident should have received Chopped beef enchilada with chili sauce, two each + 4 ounces sauce . for her mechanical soft texture diet. It was unknown 455771 Page 14 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0803 if the #8 scoop of enchilada equated to 2 enchiladas with 4 ounces of sauce. Level of Harm - Minimal harm or potential for actual harm On 12/14/23 at 9:56 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. Regarding following the menu, he stated Dietary staff A went to a scoop from a spatula when serving the enchiladas. He stated that with the use of the #8 scoop, it was unknown if it was two, three, or less enchiladas served in the #8 scoop serving. He added, he told Dietary staff A she needed more pans of enchiladas prepared. Regarding the incorrect scoop sizes, he stated Dietary staff A did what she wanted to do. He stated Dietary staff A aid she was a cook, but he saw indications that required more training and gave her more. He stated to ensure the menu was followed, he printed the menus, and tray card so they would know what was needed and gave staff the tools needed. He stated he and staff were responsible to ensure that the menu was followed. Regarding what could result from the menu not being followed, he stated decreased resident expectations and we get complaints. Residents Affected - Some On 12/14/23 at 11:47 AM an interview was conducted with Dietary staff A. She stated, she changed from a spatula to an #8 scoop for the enchiladas because they had gotten cooked and fell apart. She added, The #8 scoop is a normal serving. I did not want it (enchiladas) to look too messy. She stated, she used the #10 scoop instead of a #6 for the puréed enchiladas because the facility only had one #6 scoop. She added there were not many #10 scoops available. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. She stated that she was unsure why the staff did not follow the menu. She added the person responsible for ensuring the menu was followed was the Dietary Manager and the result of not following the menu could be a potential change in weight and nutrition for residents. Record review of the facility's, Diet Roster - By Texture dated 12/12/23 revealed the following documentation: Resident #2 - Regular (diet), purée (texture) diet. Resident #7 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet. Resident #22 - Regular (diet), 2 gm sodium (diet other), mechanical soft (texture) diet, Resident #25 - Regular (diet), purée (texture) diet. Record review of the facility Diet Spreadsheet, Menu: .Week 1, Day: 3 - Tuesday Lunch revealed that residents on a regular diet should have received: Beef enchiladas with chili sauce 2 each + 4 ounces sauce, Cilantro Lime [NAME] #8 dip Charro beans 4 ounce spoodle (draining ladle) -Residents on mechanical soft diets should have received: Chopped beef enchilada with chili sauce, two each + 4 ounces sauce. 455771 Page 15 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0803 Cilantro, lime rice with salsa #8 dip + 2 ounces Level of Harm - Minimal harm or potential for actual harm Charro beans 4 ounce spoodle (draining ladle). -Residents on purée diets should have received: Residents Affected - Some Puréed beef and enchilada with chili sauce #6 dip Purée, Cilantro Lime Rice, #10 dip. Purée Charro beans #8 dip Record review of the facility's recipe titled Beef Enchiladas with Chili Sauce, Recipe Number: 195614 revealed the following documentation. To serve: serve two beef enchiladas with 4 ounces prepared and heated chili sauce over all . Record review of facility's recipe titled Chopped Beef Enchilada with Chili Sauce, Recipe Number: 195615, revealed the following documentation, . To serve: serve two beef enchiladas hand chopped into bite-size pieces with 4 ounces prepared and heated chili sauce over all . Record review of the facility policy titled Nutrition and Food Service Policies and Procedures Manual, Section 3-11, Policy: Tray Service, Policy Number: 03.006 Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that accurate tray service and adequate portion sizes are essential to the resident's well-being and safety. The facility will ensure that diets are served accurately, and in the correct portions, and that resident's preferences are met. Procedure . 3. For tray line service, Nutrition and Food Service staff will check each resident's tray card prior to service to ensure their preferences and dislikes are honored, the correct diet is served, portion sizes are accurate and appropriate substitutions provided . 6. The Nutrition and Food Service Manager or consultant . will conduct in-services with the nutrition, food services as needed to ensure all serving staff are familiar with portion, sizes and therapeutic and mechanically altered diets . Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, Policy: Test Trays, Policy Number: 10.001, Date Approved: October 1, 2018, reveal the following documentation, Policy: the facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable, and served at the correct temperatures. Routine test tray will be evaluated by the Nutrition and Food Service Manager or designated employee. Procedure: 1. The Nutrition and Food Service Manager or designated employee will conduct a test tray evaluation at least once each month. The evaluation will be conducted at each meal to ensure that food temperatures, portion sizes, and that orders are followed. A sample test tray checklist is attached. 2. A test tray checklist should be completed at least monthly at each meal service site to ensure that temperatures, palatability, and accuracy are maintained at each location . 455771 Page 16 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 1 of 1 meal reviewed for palatability. Residents Affected - Some 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (12/14/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 1 of 12 residents voiced concerns related to food palatability. During a confidential interview on 12/12/23 at 9:50 AM, a resident stated she did not like to eat in her room for meals because the food was cold by the time it got to her. The resident stated staff would warm up the food for her if she asked, but it would still be cold at times. The resident stated she had complained about this issue before, but nothing was changed. On 12/13/23 at 10:54 AM, an interview was conducted with the Dietary Manager, and he was informed of a test tray request for hall carts. Observation on 12/13/23 at 11:19 AM revealed Dietary staff E took temperatures on the service line with the following results: Seasoned [NAME] beans, 206°F. Mashed potatoes 208.4°F. Smothered Pork chops with gravy 193.4°F. Purée seasoned green beans 204°F. Purée pork chops 204°F. Ground pork chop 195°F. Puréed bread no temperature taken and stored at room temperature. Hall tray meal service started at 11:27 AM on 12/13/23. Observation revealed the last Pod B (JH) unit tray was prepared at 11:41 AM. The sample tray preparation began at 11:41 AM and ended at 11:42 AM. The unheated cart left the kitchen at 11:44 AM. The cart arrived at Pod B unit at 11:47 AM. The service for B100 pod trays started at 11:48 AM and ended at 11:51 AM. At 11:51 AM the cart arrived on the B200 pod and staff began serving trays at 11:52 AM and the doors were open on the cart. The staff were checking and identifying trays on the cart and uncovering trays. The doors were closed on the cart at 11:56 AM. The cart left for the B300 unit at 11:56 AM. It arrived on the unit at 11:57 AM and staff started serving at 11:57 AM and the doors were left open. The doors were left open to the cart until 12:01 PM. The last tray for the B unit was 455771 Page 17 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0804 served to Resident #15 at 12:02 PM. The resident began eating at 12:08 PM. Level of Harm - Minimal harm or potential for actual harm The test observation began on 12/13/23 at 12:11 PM with the following results: Seasoned [NAME] beans - 120°F bland. Residents Affected - Some Smothered Pork chop with gravy - 122°F bland and dry Mashed potatoes - 130°F bland and had an instant flavor. Ground pork with gravy on top - 128°F had an off flavor unlike pork, tangy, old/stale flavor. Puréed pork - 115°F. There were bits and pieces of whole pork. Puréed bread - 102°F had a tangy off flavor unlike bread. Puréed seasoned green beans - 110°F Cold, flat on the plate and had elevated pepper flavor. Seven of nine foods tested had palatability issues of temperature, flavor, and appearance. On 12/14/23 at 9:50 AM an interview was conducted with the Dietary staff E. She stated that she was unsure why the pork chops were dry. She stated she followed the recipe on the pork chops, but the thyme was missing. She added she used chicken base, onions, and heavy cream and the mashed potatoes were a powder mix. On 12/14/23 at 9:56 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. He stated he told staff to follow the recipe and had told them many times. He stated, green beans may have gotten cold by sitting there and got cold after being prepared. He added staff may have turned the steam table off. He stated, he monitored the palatability of foods by tasting the food and monitor staff. He further stated he and the staff were responsible for the palatability of food. He stated he was not present in the kitchen all day. He added he would attend resident counsel if invited. He stated the last Resident Council meeting he attended was in June 2023. He added he addressed grievances individually. He stated unpalatable food could affect residents happiness and decrease independence. He added, good food made residents happy. On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. She stated that she was unsure why the food palatability issues occurred. She added the person responsible for food palatability was the Dietary Manager and the result of these issues could be possible weight loss and residents not eating the food. Record review of the Resident Council Minutes dated 9/18/23 revealed a resident comment that stated, Food Service - stop making (resident) eggs hard . Record review of the Resident Council Minutes dated 10/23/23 revealed resident comments that stated, Old Business. Dietary . would help to get plate warmers, not cold food. Food does come cold often. Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, Policy: Test Trays, Policy Number: 10.001, Date Approved: October 1, 2018, reveal the following 455771 Page 18 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documentation, Policy: the facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Routine test tray will be evaluated by the Nutrition and Food Service Manager or designated employee. Procedure: 1. The Nutrition and Food Service Manager or designated employee will conduct a test tray evaluation at least once each month. The evaluation will be conducted at each meal to ensure that food temperatures, portion sizes, and that orders are followed. A sample test tray checklist is attached. 2. A test tray checklist should be completed at least monthly at each meal service site to ensure that temperatures, palatability, and accuracy are maintained at each location . 455771 Page 19 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

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 maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 4 of 5 residents (Residents #13, #14, #21, and #66) and 3 of 3 staff (LVN D, CNA B, and CNA C) reviewed for infection control. Residents Affected - Some 1. LVN D failed to perform hand hygiene between glove changes during wound care for Resident #14 and Resident #66. 2. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #13. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #21. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #14 A record review of Resident #14's face sheet, dated 12/13/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include parkinson's disease (progressive nervous system disorder), chronic respiratory failure (lung disease) and chronic pain syndrome. Record review of Resident #14's significant change Minimum Data Set (MDS) assessment, dated 10/26/23, revealed Resident #14 was understood and had a BIMS score of 10 which indicated the resident's cognition was moderately impaired. Record review of Resident #14's order listing report, dated 12/13/23, revealed the following orders: -Cleanse left outer foot with NS or wound cleanser, pat dry, apply calcium alginate, cover with silicone bordered dressing daily and prn every 1 hour as needed for saturation, with a start date of 12/08/23. -Cleanse sacrum wound with NS or wound cleanser, pat dry, apply anacept, pack and apply calcium alginate, and cover with silicone bordered dressing daily and prn every 1 hour as needed for wound tx, with a start date of 12/13/23. During an observation on 12/13/23 at 9:41 AM, LVN D walked in the room and performed hand hygiene using ABHR. LVN D donned (put on) a pair of clean gloves and removed the old dressing to Resident #14's sacral wound. LVN D cleansed the sacral wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D packed the sacral wound with anacept (wound gel) and calcium alginate using a cotton-tipped applicator. LVN D removed her right-hand glove and placed a silicone bordered dressing on the sacral wound to cover it with one gloved hand and one ungloved hand. LVN D then removed her left-hand glove and used ABHR. LVN D donned a pair of 455771 Page 20 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0880 Level of Harm - Minimal harm or potential for actual harm clean gloves and removed the old dressing to Resident #14's left foot lateral (side) wound. LVN D cleansed the left foot lateral wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D placed calcium alginate on the left foot lateral wound bed and covered it with a silicone bordered dressing. LVN D then removed her gloves and washed her hands with soap and water. LVN D did not perform hand hygiene between every glove change. Residents Affected - Some Resident #66 Record review of face sheet for Resident #66, dated 12/13/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses to include necrotizing fasciitis (flesh eating disease), morbid obesity, and essential hypertension (high blood pressure). Record review of Resident #66's comprehensive MDS, dated [DATE] revealed Resident #66 was usually understood and had a BIMS score of 14 which indicated the resident's cognition was intact. Record review of Resident #66's order listing report, dated 12/13/23, revealed the following order: Cleanse left groin, perineum, buttock with wound cleanser or NS. Apply anacept and calcium alginate, pad with abdominal, cover with dressing daily and prn one time a day for wound tx, with a start date of 12/05/23. During an observation on 12/13/23 at 10:29 AM, LVN D walked in the room and performed hand hygiene using ABHR. LVN D donned a pair of clean gloves and removed the old dressing to Resident #66's groin wound. LVN D removed her gloves and donned a pair of clean gloves. LVN D cleansed Resident #66's groin wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D applied anacept and calcium alginate to the groin wound and covered with an abdominal pad. LVN D removed her gloves and donned a pair of clean gloves and Resident #66 was turned on her side. LVN D removed the old dressing from Resident #66's perineum/buttocks wound. LVN D removed her gloves and performed hand hygiene using ABHR. LVN D donned a pair of clean gloves and cleansed the perineum/buttocks wound with 4x4 gauze and wound cleanser, then patted dry. LVN D removed her gloves and donned a pair of clean gloves. LVN D applied anacept and calcium alginate to the perineum/buttock wound and covered with an abdominal pad, using an island dressing to hold it in place. LVN D then removed her gloves and washed her hands with soap and water. LVN D did not perform hand hygiene between every glove change. During an interview on 12/13/23 at 2:18 PM, LVN D stated she has been trained to perform hand hygiene between glove changes. LVN D stated she did not know why she did not perform hand hygiene between every glove change. LVN D stated the residents are at risk of infection or bringing bacteria in due to the lack of hand hygiene between glove changes. Resident #13 Record review of face sheet for Resident #13, dated 12/12/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses to include hemiplegia and hemiparesis (one-sided paralysis), dysphagia (difficulty swallowing), and aphasia (language disorder). Record review of Resident #13's comprehensive MDS, dated [DATE] revealed that Resident #13 was sometimes understood and had a staff assessment for mental status that revealed Resident #13's cognition was moderately impaired. 455771 Page 21 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 12/13/23 at 1:21 PM, CNA B performed incontinence care for Resident #13 with the help of CNA C. CNA B washed her hands with soap and water and donned a pair of clean gloves. CNA B unfastened Resident #13's brief and pulled it down. CNA B removed her gloves and donned a pair of clean gloves. CNA B wiped the groin area with wipes and removed her right-hand glove. CNA B then donned a clean glove to her right hand, Resident #13 was turned on her side and CNA B then wiped her buttocks. CNA B removed the old brief and removed her gloves. CNA B performed hand hygiene using ABHR and donned a clean pair of gloves. CNA B applied barrier cream to Resident #13's buttocks with her right hand, then removed her right-hand glove. CNA B donned a clean glove to her right hand and a clean brief was placed under the resident and fastened. CNA B then removed her gloves and performed hand hygiene using ABHR. CNA B did not perform hand hygiene between every glove change. Resident #21 Record review of Resident #21's face sheet dated 12/12/23 revealed a [AGE] year-old female with an admission date of 08/07/18 with the following diagnoses: dementia (cognitive loss), acute and chronic respiratory failure (lung disease), and depression (mood disorder). Record review of Resident #21 comprehensive MDS dated [DATE] revealed Resident #21 was sometimes understood and had a staff assessment for mental status that indicated her cognition was moderately impaired. During an observation on 12/13/23 at 1:33 PM, CNA C performed incontinence care for Resident #21 with the help of CNA B. CNA C washed her hands with soap and water and donned a pair of clean gloves. CNA C unfastened Resident #21's brief and pulled it down. CNA C removed her gloves and donned a pair of clean gloves. CNA C wiped the groin area, removed her gloves and performed hand hygiene using ABHR. CNA C donned a pair of clean gloves and Resident #21 was turned on her side. CNA C wiped a bowel movement from Resident #21's buttocks and CNA C's gloves became visibly soiled. CNA C removed her gloves and donned a pair of clean gloves. CNA C wiped the buttocks until all the bowel movement was cleaned off and removed the old brief. CNA C removed her gloves and donned a clean pair of gloves. CNA C placed a clean brief under Resident #21 and applied barrier cream with her right hand. CNA C removed her right-hand glove and donned a clean glove to her right hand. CNA C secured the brief on Resident #21, removed her gloves and washed her hands with soap and water. CNA C did not perform hand hygiene between glove changes or when her gloved hands became visibly soiled. During an interview on 12/13/23 at 1:42 PM, CNA B and CNA C stated that they have been trained to perform hand hygiene between every glove change. CNA B and CNA C stated they were nervous and that is why they forgot. CNA B and CNA C stated the residents are at risk of cross-contamination due to the lack of hand hygiene between glove changes. During an interview on 12/14/23 at 9:18 AM, the DON stated she expected the staff to sanitize their hands between glove changes. The DON stated she expected staff to wash their hands with soap and water if their gloves became visibly soiled. The DON stated she expected staff to remove both right- and left-hand gloves when changing gloves during resident care. The DON stated the ADON, and she were responsible for ensuring staff adhered to infection control policies by making quality rounds throughout the day. The DON stated she did not know why the staff failed to perform hand hygiene between glove changes, they were probably nervous. The DON stated the residents had increased infection control risks due to the lack of hand hygiene between glove changes, only changing one glove during care and not washing hands with soap and water when gloves became visibly soiled. The DON stated she would have to look up training for LVN D, CNA B, and CNA C regarding infection control and hand 455771 Page 22 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0880 hygiene. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/14/23 at 9:47 AM, the ADM stated she expected staff to perform hand hygiene between glove changes and to wash their hands with soap and water if their gloves became visibly soiled. The ADM stated the DON and ADON/Infection Control Nurse were responsible for ensuring staff adhered to infection control policies. The ADM stated staff were being trained during their on boarding to the facility, so she did not know why staff did not perform hand hygiene as they should. The ADM stated the potential negative outcome to the residents were possible infection risks. Residents Affected - Some During an interview on 12/14/23 at 10:39 AM, the ADON stated she expected staff to sanitize their hands between glove changes. The ADON stated she expected staff to remove both gloves during resident care when going from dirty to clean, perform hand hygiene and put on clean gloves. The ADON stated she expected staff to perform proper handwashing (meaning soap and water) when their gloves became visibly soiled. The ADON stated as the infection preventionist for the facility, the DON and she were responsible for ensuring staff were washing their hands between glove changes or when their gloves became visibly soiled. The ADON stated she did not know why the staff removed only one glove during resident care instead of both gloves. The ADON stated staff could not see if the other glove was dirty with bacteria not seen by the eye, so they should have changed both gloves instead of just one. The ADON stated the staff were probably nervous and that is why they forgot to perform hand hygiene between every glove change. The ADON stated the potential negative outcome to the residents were infection transmission risks. Record review of facility's Treatment Nurse Competency Check Off which included hand washing for LVN D revealed she completed this check off on 11/08/23 with a met status. Record review of facility's Record of Inservice - Infection Control, dated 05/01/23 revealed the following: -Objectives of the in-service: Please be mindful that it is very important to wash your hands and change gloves between patients. -Brief evaluation of the participants' responses to the in-service: This helps prevent infection control and keeps down on resident complaints. CNA B and CNA C's signatures were noted on the in-service form. Record review of the facility's Record of In-Service: Infection Control, dated 05/07/23 revealed the following: Objectives of the In-Service: Gloves are not to be stored in your pockets. They are also not to be pulled out of the rooms. Part of Infection Control is handwashing. You are required to wash your hands upon entering the room(s) and before leaving the room(s). Room will/are stocked every Monday and Friday. Brief evaluation of the participants' responses to the in-service: Again please do not pull gloves out of the residents room/bathrooms. Thank you. CNA B and CNA C's signatures were noted on the in-service form. Record review of the facility's Record of In-Service: Dignity/Resident Rights, dated 08/09/23 revealed the following: 455771 Page 23 of 24 455771 12/14/2023 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Objectives of the in-service: When giving peri-care please ensure that you first 1. Knock on the door. 2. Wash your hands. 3. Pull privacy curtain. 4. Close blinds. Brief evaluation of the participants' responses to the in-service: These in-services are all final warnings. Please ensure that you follow all residents rights and dignity rights. CNA B and CNA C' signatures were noted on the in-service form. Record review of the facility's policy, titled Infection Prevention and Control Program, with a revised date of September 2022 reflected the following: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections Record review of facility policy titled Handwashing/Hand Hygiene, with a revised date 08/19 revealed the following: Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. when hands are visibly soiled . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. before moving from a contaminated body site to a clean body site during resident care; k. after handling used dressings, contaminated equipment, etc; m. after removing gloves . 9.The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections 455771 Page 24 of 24