Health inspection·January 30, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #10) reviewed for care plans. The facility failed to include Resident #10 was receiving hospice services in the comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Record review of Resident #10's face sheet dated 01/30/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: diabetes (a group of diseases that result in too much sugar in the blood), hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). Record review of Resident #10's admission MDS assessment dated [DATE], reflected that Resident #10 had a BIMS score of 07 which reflected the resident was severely cognitively impaired. Resident #10's admission MDS assessment reflected that the resident was receiving hospice care. Record review of Resident #10's Physician's Orders, dated 12/05/24, reflected the resident had an order for: Admit to Hospice. Record review of care plan dated 11/13/2024 reflected Resident #10 was not care planned for receiving hospice services. In an observation and interview on 01/28/25 at 12:21 PM, Resident #10 stated she was doing ok. She stated staff treated her well and she had everything she needed. Resident appeared pleasantly confused and was clean and dressed appropriately with no sign of pain or distress noticed. In an interview on 01/30/25 at 09:52 AM, the MDS nurse stated he was responsible for completing care plans. He stated there was a group of staff that were included in completing care plans as well, Page 1 of 5 455771 455771 01/30/2025 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0656 Level of Harm - Minimal harm or potential for actual harm but he was responsible for completing the hospice care plans. He stated he had been trained to complete care plans accurately. He stated if a resident received hospice services, it should have been included in their care plan. He stated he was aware Resident #10 received hospice services, but he was not aware that Resident #10's care plan had not included hospice services. He stated he thought there could be a negative impact on resident's if they received hospice services and it was not care planned. Residents Affected - Few In an interview on 01/30/25 at 10:00 AM, the DON stated the MDS nurse was ultimately responsible for completing the care plans and he was responsible for care planning hospice services. She stated her and other staff reviewed the care plans as a group and made the MDS nurse aware if there were changes that needed to be made. She stated the MDS nurse and other staff had been trained on completing care plans accurately. She stated it was her expectation that hospice services be care planned. She stated she was aware that Resident #10 received hospice services. She stated she was not aware that Resident #10 was not care planned for hospice services, but she knew that Resident #10 should have been care planned for hospice services. She stated if hospice was not included in a resident's care plan or a care plan was completed inaccurately, it could have caused a delay in care or interventions, or certain things may or may not have happened if they were not care planned. Review of facility policy dated 2001 (complete revision December 2016) titled Care Plans, Comprehensive Person-Centered revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; d. At least quarterly, in conjunction with the required quarterly MDS assessment. 455771 Page 2 of 5 455771 01/30/2025 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 observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control. Residents Affected - Few The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident #17's undated face sheet, reflected she was an [AGE] year-old female admitted [DATE] with diagnoses of Encephalopathy (brain disfunction), Acute Respiratory Failure, Diabetes, Pneumonia, Anxiety, and Major Depressive Disorder. Record review of Resident #17's Quarterly MDS assessment dated Dec. 25, 2024, reflected a BIMS score of 06, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #17's Care Plan, reflected a Focus area was initiated for Acute Infection on 11/21/24 with a goal for the infection to resolve without complications. Record review of Resident #44's undated face sheet, reflected she was a [AGE] year-old female admitted [DATE] with diagnoses of Dementia, Depression, High Blood Pressure, and a Personal History of Urinary Tract Infections. Record review of Resident #44's Quarterly MDS assessment dated Dec. 24, 2024, reflected a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #44's Care Plan, reflected a Focus area was initiated for Resident is at risk for infection-Covid 19 with a goal to not exhibit signs and symptoms of Covid-19. Observation on 1/29/25 at 9:03 a.m., revealed MA removed a blood pressure cuff from the top of the medication cart and entered the resident's room to take the blood pressure of Resident #17. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #17 in the resident's room. She returned to the medication cart and moved to the next resident without performing hand hygiene or cleaning the blood pressure cuff. Observation on 1/29/25 at 9:15 a.m., revealed MA removed the un-sanitized blood pressure cuff from the top of the medication cart and proceeded to take the blood pressure of Resident #44. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #44 in the resident's room. She returned to the medication cart and moved the cart back to the nurse's station where she left it. The blood pressure cuff was left on top of the first medication cart and was never sanitized. Hand 455771 Page 3 of 5 455771 01/30/2025 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 - Few hygiene was not done until MA moved to a different cart, where she performed hand hygiene before starting on the new cart. In an interview on 01/29/25 09:44 a.m., MA stated she forget the hand hygiene between Resident #17 and Resident #44 but does not know why. She stated that she did not clean the blood pressure cuff between residents. She stated she usually keeps the hand sanitizer near her on the cart and does do it. She stated it was important to do hand hygiene and clean the cuff to avoid spreading infections from resident to resident. She stated that the negative outcome to residents if it was not done, was they could develop infections and get sick. In an interview on 1/30/25 at 9:54 a.m., the DON stated, the policy for hand hygiene during medication administration was to clean hands before and after each resident and as needed. She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this is important for infection control and to not spread germs between residents which could give a resident an infection and make them sick. She said it was the responsibility of the DON, the Scheduler, and the ADON to train staff on this when staff is hired and at yearly competencies. In an interview on 1/30/25 at 10:28 a.m., RN, she stated the policy for hand hygiene on medication administration was to sanitize hands before and after each resident and as needed. She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this was important for minimize risk of spreading bacteria to other residents and causing cross contamination. She stated if this was not done, residents could get infections and become sick. She stated it was the responsibility of the DON, ADON and nurse management to train staff on this. In an interview on 1/30/25 at 10:38 a.m., the ADM stated the policy for hand hygiene on medication administration was to clean hands before and after each resident. He stated the policy on cleaning equipment like blood pressure cuffs was to clean between residents. He stated this is important for infection control and to prevent giving a resident an infection which could make them sick. He stated it is the responsibility of the DON and ADM to train staff on this. A record review of the facility policy titled, Handwashing/Hand Hygiene 2001 Med-Pass, Inc with a last revision date of 2019 reflected the following: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated before and after direct contact with residents and before handling medications. Hand Hygiene is indicated after handling contaminated equipment. A record review of the facility's undated policy titled, 9. Medication and Preparation Administration-9.2 Preparation of Medication reflected the person administering medications adheres to good hand hygiene, which includes washing or sanitizing hands: 455771 Page 4 of 5 455771 01/30/2025 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0880 Before beginning a medication pass. Level of Harm - Minimal harm or potential for actual harm Prior to handling any medication. After coming into direct contact with a resident. Residents Affected - Few When returning to the medication cart or preparation area. After each room. A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2022 reflected the following: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Durable medical equipment is cleaned and disinfected before reuse by another resident. 455771 Page 5 of 5