Health inspection·June 22, 2023

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, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #56) of fifteen residents reviewed for comprehensive care plans. The facility failed to document Resident #56's use of compression stockings in his comprehensive care plan. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings include: Record review of Resident #56's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cellulitis (bacterial skin infection) of right and left lower limbs, diabetes, and chronic congestive heart failure (chronic condition in which the heart does not pump blood as it should). Record review of Resident #56's quarterly MDS assessment dated [DATE] reflected a BIMSs of 12, which indicated resident was moderately cognitively impaired, he required supervision with no set up or physical help from staff for his ADL needs. Resident #56 was listed to be at risk of developing pressures ulcers but had no skin conditions at the time of the assessment. Record review of Resident #56's care plan initiated 02/27/23 reflected, [Resident #56] is a diabetic and is at risk for frequent infections. Pressure/venous/stasis ulcers .Interventions included .Monitor skin for changes-redness, circulatory problems, breakdown .weekly skin assessments . There were no interventions listed for the use of compression stockings. Record review of Resident #56's Nurse's notes dated 04/01/23 by Agency LVN G, reflected, .Resident up in wheelchair assisted with putting on compression stockings .continue with Bactrim DS (antibiotic) for cellulitis and Metolazone (diuretic) R/T edema . An observation and interview with Resident # 56 on 06/20/23 at 10:10 a.m. revealed the resident lying in bed. Resident had compression stockings on both lower legs which were dirty and stained. When asked if the facility helped him put his compression stockings on, he stated no, he put them on. When asked if had a clean pair he could swap out he stated no, the other pair was dirty also. He stated Page 1 of 18 455806 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0656 he never took them off because they were so hard to put on. Level of Harm - Minimal harm or potential for actual harm In an interview with can B on 06/21/23 at 11:00 a.m., she stated they did not assist Resident #56 with his compression stockings because there was no order for them. She stated she did not assist him with his showers, stating he was a 2 to 10 p.m. shower. She stated she knew he was wearing compression stockings but stated she did not know if anyone was helping him put them on or not. Residents Affected - Few In a follow up interview with Resident #56 on 06/21/23 at 12:50 p.m., Resident #56 stated he took a shower yesterday (06/20/23). He stated he did not need assistance with his showers, just someone to hand him towels. When asked if someone assisted him with his compression stockings he stated no he just showered with them on. He stated he had not taken off his compression stockings in at least 2 weeks. In an interview with the DON on 06/21/23 at 01:30 p.m., she stated any resident who was using compression stockings had to have a physician order for the use of those stockings with when to put them on and when to take them off. She stated at no time were they to be worn 24 hours a day. She stated this could cause circulatory restriction and if there was a crease or a wrinkle it could cause skin breakdown. She stated a resident's skin needed to be assessed daily while using compression stockings. Attempted to reach Agency LVN G on 06/21/23 at 2:00 p.m. Message left with no return phone call. In an interview with CNA C on 06/21/23 at 2:45 p.m., she stated she works the 2-10 p.m. shift. She stated Resident #56 was on her shower schedule for 06/20/23, but he refused, stating he had already taken his shower earlier in the day. She stated he often refused his shower on her shift. She stated she did not recall seeing resident with compression stockings and stated he had never requested her assistance with them. In an interview with Agency LVN D on 06/21/23 at 4:05 p.m., she stated she had worked at the facility off and on for about 3 months. She stated Resident #56 was very prone to refuse assistance, but stated he was getting a little better about letting them assist him. She stated Resident #56 had always had compression stockings on when she had worked his hall. She stated approximately 3 or 4 weeks ago she had tried to get him to take them off, but he had refused. She stated she had not documented it, nor had she reported this to anyone. She stated she was aware you needed physician orders for the use of compression stockings, and they should be taken off daily. She stated she was not aware of when Resident #56 skin assessment were to be done. In an interview with the MDS nurse on 06/21/23 at 3:10 p.m., she stated she was responsible for updating the comprehensive care plan. She stated the care plan was supposed to be a comprehensive approach to what the needs of the resident were or what their wished were. She stated compression stockings should be care planned as well as any behaviors related to refusal of care. She stated they should have known the resident was putting on compression stockings and should have had interventions in place. She stated she worked the floor 2 weeks ago and was aware the resident frequently refused care but was not aware he was wearing compression stockings. An interview with the DON on 06/22/23 at 11:50 a.m. revealed the MDS Coordinator was responsible for updating the care plan but stated any of the administrative staff could update the care plan as needed. She stated the use of compression stockings should be care planned. She stated failing to have interventions in place put residents at risk of skin breakdown and decrease in circulation. 455806 Page 2 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy titled Care Plan Process, Person Centered Care , dated May 2023, reflected, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care .The Interdisciplinary Team will review for effectiveness and revise the care plan after each assessment .Thru ongoing assessment, the facility will initiate care plans when the resident's clinical status or change of condition dictates the need .The person centered care plan will include .Problem .Interventions, discipline specific services, and frequency .Refusal of services and/or treatments .Attempts to find alternative means to address the identified risk/need . 455806 Page 3 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #23, Resident #44, Resident #49, and Resident#24) of 16 residents reviewed for ADLs. Residents Affected - Some The facility failed to ensure: 1- Resident#23 had her fingernails cleaned and trimmed. 2- Resident#43 had her fingernails cleaned and trimmed. 3- Resident#49 had his fingernails cleaned and trimmed. 4- Resident#24 had her facial hair under her chin trimmed These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: 1- A record review of Resident #23's Quarterly MDS assessment dated [DATE] reflected Resident #23 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and lack of coordination. Resident #23 had a BIMS of 02 which indicated Resident #23's cognition was severely impaired. She required extensive assistance of two-person physical assistance with transfers, dressing, and personal hygiene. A record review of Resident #23's Comprehensive Care Plan, revised 03/03/23, reflected Problem: My ADL function: Bed mobility, transfers, dressing, eating, toileting, personal hygiene, bathing. Goal: I will maintain a sense of dignity by being clean, dry, odor free and well groomed over next 90 days. Approach: Assist with ADLs as needed. An observation on 06/20/23 at 1:36 PM revealed Resident #23 was sitting in her wheelchair. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue, and the nails' beds had dark brown color. Resident #23 unable to answer questions. 2- A record review of Resident #43's Quarterly MDS assessment, dated 04/14/2023, reflected Resident #43 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and lack of coordination. Resident #43 had a BIMS of 03 which indicated Resident #43's cognition was severely impaired. Resident#43 required extensive assistance of one-person physical assistance with dressing and personal hygiene. A record review of Resident #43's Comprehensive Care Plan revised 06/20/23 reflected Problem: My 455806 Page 4 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ADL function: Bed mobility, transfers, dressing, eating, toileting, personal hygiene, bathing. Goal: I will maintain a sense of dignity by being clean, dry, odor free and well-groomed over next 90 days. Approach: Assist with ADLs as needed. Observation on 06/20/23 at 1:45 AM revealed Resident #43 was laying in her bed. The nails on both hands were approximately 0.2 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #43 was confused and unable to answer questions. 3- A record review of Resident #49's Comprehensive MDS assessment, dated 05/20/2023, reflected Resident #49 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included muscle weakness, lack of coordination, and need for assistance with personal care. Resident #49 had a BIMS of 05 which indicated Resident #49's cognition was severely impaired. Resident#49 required extensive assistance of two-person physical assistance with dressing and personal hygiene. A record review of Resident #49's Comprehensive Care Plan revised on 06/20/23 reflected Problem: My ADL function: Bed mobility, transfers, dressing, eating, toileting, personal hygiene, bathing. Goal: I will maintain a sense of dignity by being clean, dry, odor free and well-groomed over next 90 days. Approach: Assist with ADLs as needed. Observation on 06/20/23 at 1:50 AM revealed Resident #49 was laying in his bed. The nails on both hands were approximately 0.2 centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue, and the nails' beds had dark brown color. Resident #49 unable to answer questions. Interview on 06/21/23 at 10:30 AM, CNA H stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA H stated she would clean and trim the nails for Resident #23 and Resident #49. CNA H stated Resident #43 was diabetic and the nurse should have trimmed her nails. CNA H stated she did not noticed Resident #43's nails. CNA H stated fingernail care was provided for the residents during daily care. Interview on 06/21/23 at 10:34 AM, LVN I stated CNAs were responsible to clean and trim residents' nails as needed. LVN I stated only nurses cut residents' nails if they were diabetic. LVN I stated no one notified her Resident #43's nails were long and dirty, and she had not noticed the nails herself. LVN I stated Resident#23 and Resident #49 scratched their bottoms. LVN I stated she would clean and trim their nails. Interview on 06/21/23 at 11:25 AM, the Interim DON stated nail care should be completed as needed and every time aides wash the residents' hands. The Interim DON stated nails should be observed daily by nursing staff. The Interim DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The Interim DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The Interim DON stated residents having long and dirty nails could be an infection control issue. The Interim DON stated she would do routine rounds for monitoring. Review of the facility's policy titled, Fingernail Care dated 7/1/2013, reflected, .7. Cleans under nails with orange stick. 8. [NAME] nails with nail scissors, clippers or file . 4-Review of Resident #24's Annual MDS assessment dated [DATE] reflected Resident #24 was a [AGE] 455806 Page 5 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Heart Disease, Heart Failure, Peripheral Vascular Disease (circulation disorder that affect blood vessels outside of the heart or brain), Diabetes, Stroke, Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems) and Respiratory Failure . She had a BIMS of 15 indicating she was cognitively intact. Resident #24 required extensive assistance with two-person physical assistance with personal hygiene. Observation on 06/20/23 at 12:41 PM with Resident #24 revealed she had facial hair under her chin of about ¼ inch long in area of 1.5 x 2 inches. Interview on 06/20/23 at 12:42 PM revealed Resident # 24 did want her facial hair under her chin trimmed but it was not done by the CNAs. She stated she was dependent on staff to trim the facial hair and was not able to do it herself. She stated on shower days, she was not asked if she would like it trimmed and sometimes on her shower days she forgets to ask them to trim it. She stated she was showered on MWF when she wanted it. She stated she sometimes refused to be showered if she did not have consistent staff showering her. She stated she had not refused to have her facial hair trimmed. Interview on 06/20/23 at 12:48 PM with CNA I revealed Resident # 24 was a 2 pm to 10 pm shower who did refuse showers at times but was not sure if she had refused facial hair trimming. She stated she would start to offer to Resident #24 if she wanted her facial hair trimmed. She stated when on shower days for each resident, that is when a resident can get facial hair trimmed if he or she wanted it. Interview on 06/22/23 at 9:52 AM with Interim DON revealed Resident #24 should have been offered by the CNAs if she wanted her facial hair trimmed at least on shower days or when staff notices facial hair on a resident. Review of facility's policy Activities of Daily Living, Optimal Function revised 05/05/23 reflected the facility provides necessary care to all residents to ensure they maintain proper .grooming, and hygiene. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs. Review of the facility's policy titled, Fingernail Care dated 7/1/2013, reflected, .7. Cleans under nails with orange stick. 8. [NAME] nails with nail scissors, clippers or file . 455806 Page 6 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for one (Resident #56) of fifteen residents reviewed for quality of care. Residents Affected - Some 1. The facility staff failed to obtain physician orders for the use of compression socks for Resident #56. 2. The facility staff failed to perform weekly skin assessments for the month of June 2023 for Resident #56. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in undetected skin issues and delay in treatments. Findings included: Record review of Resident #56's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cellulitis (bacterial skin infection) of right and left lower limbs, diabetes, and chronic congestive heart failure (chronic condition in which the heart does not pump blood as it should). Record review of Resident #56's quarterly MDS assessment dated [DATE] reflected a BIMSs of 12, which indicated resident was moderately cognitively impaired, he required supervision with no set up or physical help from staff for his ADL needs. Resident #56 was listed to be at risk of developing pressures ulcers but had no skin conditions at the time of the assessment. Record review of Resident #56's care plan initiated 02/27/23 reflected [Resident #56] is a diabetic and is at risk for frequent infections. Pressure/venous/stasis ulcers .Interventions included .Monitor skin for changes-redness, circulatory problems, breakdown .weekly skin assessments . There were no interventions listed for the use of compression stockings. Record review of Resident #56's Physician order Report dated 06/01/23 to 06/30/23 reflected no orders for the use of compression stockings. Record review of Resident #56's MAR and TAR for June 2023 did not reflect the use of compression stockings nor indicate a weekly skin assessment was completed. Record review of Resident #56's Nurse's notes dated 04/01/23 by Agency LVN G, reflected, .Resident up in wheelchair assisted with putting on compression stockings .continue with Bactrim DS (antibiotic) for cellulitis and Metolazone (diuretic) R/T edema . Record review of Resident #56's Nurse's notes dated 05/25/23 by Agency LVN G, reflected, Resident with bilateral 3+ edema. MD notified .N. O Increase to Torsemide 40 mg daily r/t bilateral edema . Record review of the facility's weekly schedule for skin assessment week ending 05/29/23 (most recent on file) reflected Resident # 56 was scheduled for skin assessments on Thursdays. 455806 Page 7 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Nursing Data collection tool dated 05/26/23 for Resident #56 reflected, Skin condition .Warm and dry . No skin issues were present at the time of the assessment. In an observation and interview with Resident # 56 on 06/20/23 at 10:10 a.m. revealed the resident lying in bed. Resident had compression stockings on both lower legs which were dirty and stained. When asked if the facility helped him put his compression stockings on, he stated no, he put them on. When asked if had a clean pair he could swap out, he stated no, the other pair was dirty also. He stated he never took them off because they were so hard to put on. In an interview with CNA B on 06/21/23 at 11:00 a.m., she stated they did not assist Resident #56 with his compression stockings because there was no order for them. She stated she did not assist him with his showers, stating he was a 2 to 10 p.m. shower. She stated she knew he was wearing compression stockings but stated she did not know if anyone was helping him put them on or not. In a follow up interview with Resident #56 on 06/21/23 at 12:50 p.m. Resident #56 stated he took a shower yesterday (06/20/23). He stated he did not need assistance with his showers, just someone to hand him towels. When asked if someone assisted him with his compression stockings he stated no he just showered with them on. He stated he had not taken off his compression stockings in at least 2 weeks. In an observation with the ADON and the Treatment Nurse on 06/21/23 at 1:15 p.m., Resident #56's compression stockings were removed to perform a skin assessment. Resident #56 had a scabbed area approximately the size of a triple A battery on the top of his right ankle at the bend of his foot. The ADON stated she would notify the Physician and obtain a treatment order and see if he wanted to continue the use of the compression stockings. In an interview with the DON on 06/21/23 at 01:30 p.m., she stated any resident who was using compression stockings had to have a physician order for the use of those stockings with when to put them on and when to take them off. She stated at no time were they to be worn 24 hours a day. She stated this could cause circulatory restriction and if there was a crease or a wrinkle it could cause skin breakdown. She stated a resident's skin needed to be assessed daily while using compression stockings. She stated she was unsure why the weekly skin assessment had not been completed. She stated she had just started at the facility as interim DON around the first of June 2023. Attempted to reach Agency LVN G on 06/21/23 at 2:00 p.m. Message left with no return phone call. In an interview with the ADON on 06/21/23 at 2:30 p.m., she stated the staff used to perform all skin assessment on Friday of each week. She stated that was the standing schedule. She stated the previous DON who started in May of 2023 changed the weekly skin assessments and spread them out on Tuesdays and Thursdays. She stated when the DON left at the end of May 2023, they failed to put a new schedule on the treatment book. She stated her routine nursing staff had continued to do the skin assessments as they had previously done them, but the hall Resident #56 resided on was staffed mainly by Agency staff, and the skin assessments got overlooked for June 2023. In an interview with CNA C on 06/21/23 at 2:45 p.m., she stated she works the 2-10 p.m. shift. She stated Resident #56 was on her shower schedule for 06/20/23, but he refused, stating he had already taken his shower earlier in the day. She stated he often refused his shower on her shift. She stated she did not recall seeing resident with compression stockings and stated he had never requested her assistance with them. 455806 Page 8 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with Agency LVN D on 06/21/23 at 4:05 p.m. she stated she worked at the facility off and on for about 3 months. She stated Resident #56 was very prone to refuse assistance, but stated he was getting a little better about letting them assist him. She stated Resident #56 had always had compression stockings on when she had worked his hall. She stated approximately 3 or 4 weeks ago, she had tried to get him to take them off, but he had refused. She stated she had not documented it, nor had she reported this to anyone. She stated she was aware physician orders were needed for the use of compression stockings, and they would be taken off daily. She stated she was not aware of when Resident #56's skin assessments were to be done. In an interview with the MD on 06/22/23 at 10:00 a.m., he stated he came to the facility on [DATE] to assess Resident #56's wound on his right ankle. He stated it appeared to be a skin tear which had no signs of infection or maceration (occurs when skin has been exposed to moisture). He stated the wound looked new. He stated he discontinued the use of the compression stockings and stated he would re-evaluate later to see if he would require them in the future. He stated he was unaware the resident had been using the compression stockings and assumed he had had brought them with him when he was discharged from the hospital. He stated if the resident needed them in the future, they would have him measured for the appropriate amount of compression needed to provide a therapeutic response. In an interview with the Mobile DON on 06/22/23 at 11:45 a.m. revealed the facility did not have policy for compression stockings, just a procedure which stated to follow manufacturer's guidelines. She stated Resident #56 was the only Resident using compression stockings in the facility. She stated they had completed a skin sweep on 06/21/23 of all the residents and found no additional unidentified skin issues. Review of the facilities policy titled, Licensed Nurse Skin Checks, dated June 2015 reflected, All patients/residents will have a thorough weekly skin evaluation performed by a Licensed Nurse .Weekly, the Licensed Nurse performs a head to toe check of the patient's/resident skin, paying particular attention to .the surfaces of the skin that come in contact with the bed and chair .Bony prominences .the surfaced of the skin that come in contact with any orthotic device, tube, brace, or positioning device .skin folds .Documentation that the check was performed is denoted on the Medication Administration Record (MAR), Treatment Administration Record ( TAR ) or Weekly skin Documentation Form .Abnormal findings to be documented in the Nurse's Notes or to be documented on the back of the TAR if space allows . Review of National Institute of health's webpage https://medlineplus.gov/ency/patientinstructions/000597.htm, searched on 06/26/23 reflected, You wear compression stockings to improve blood flow in the veins of your legs .If you have varicose veins, spider veins, or have just had surgery your health care provider may prescribe compression stockings .Follow instructions on how long each day you need to wear your compression stockings .Wash the stockings each day .rinse and air dry .Replace your stockings every 3 to 6 month . 455806 Page 9 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two (Residents #15 and #58) of four residents reviewed for pharmacy services. 1. Agency LVN A failed to follow the manufacturer's instructions to [NAME] the Humalog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #15. 2. Agency LVN A failed to flush Resident #58's G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) with 60 cc water prior to and after medication administration per physician orders and failed to flush the G-tube by gravity, and instead pushed 50 cc of water prior to and after medication administration. These failures placed residents at risk of not receiving full dosage of medication, and abdominal discomfort or dislodgement of the G-tube. Findings included: 1. Review of Resident #15's undated Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus. Review of Resident #15's Physician Orders Report dated 06/01/23 to 06/30/23 reflected, . FSBS AC &HS with Humalog SQ sliding scale as follows .151 to 200 = 3 Units . An observation on 06/20/23 at 11:00 a.m. of the medication pass revealed Agency LVN A checked Resident #15's FSBS and obtained a reading of 161. Agency LVN A returned to the medication cart and disposed of the lancet and test strip and placed the glucometer on top of the medication cart. Agency LVN A still looked at MAR and determined resident would need insulin according to sliding scale and opened the medication cart and sorted through the various insulin pens in the drawer and stated she would have to go to the medication room, since there was not an insulin pen on the cart for Resident #15. Agency LVN A removed her gloves and went to the medication room and searched the refrigerator looking through multiple insulin pens but could not find a pen for Resident #15. Agency LVN A reported to the Interim DON of the need for an Insulin Pen out of the emergency kit and then returned to the medication cart to proceed with her next medication pass. An observation on 06/20/23 at 11:25 a.m. revealed a staff member delivered a new Humalog Insulin pen to Agency LVN A to be used for Resident #15. Resident #15 was at the medication cart in the hallway asking Agency LVN A for a pain pill. Agency LVN A stated she would see if it was time as soon as she gave her insulin. Agency LVN A picked up the un-sanitized glucometer to recheck the resident's previous blood sugar readings and determined it was 161. Agency LVN A put on gloves without performing hand hygiene, placed a needle on the insulin pen, and dialed 3 units without priming the pen first. Agency LVN A then administered the Insulin to Resident #15, disposed the needle, removed her gloves, and placed the pen and the un-sanitized glucometer back into the medication cart. 2. Record review of Resident #58's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admission date of 03/01/23. Resident #58 had a BIMS of 12 which indicated she was 455806 Page 10 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognitively in intact. She had active diagnoses of idiopathic neuropathy (condition that affects the peripheral nerves and has a neurological basis) and severe protein-calorie malnutrition and received 51% or more of total calories through a feeding tube. Record review of Resident #58's Physician orders report dated 06/01/23 to 06/30/23 reflected, .Flush G-tube with 60 ml of H2O before and after meds .Flush G-tube with 5 ml between meds . An observation on 06/20/23 at 11:10 a.m. of G-Tube medication administration for Resident #58 revealed Agency LVN A at the medication cart putting on gloves without performing hand hygiene, pulling 1 tablet of Tramadol (Opioid) 50 mg, 1 tablet of Baclofen (muscle relaxant) 5 mg, 1 tablet of hydroxyzine HCL (antihistamine) 25 mg and 1 capsule of Gabapentin (anticonvulsant used to treat nerve pain) 300 mg. Agency LVN A opened the capsule and placed in a plastic cup and then crushed each tablet and placed each of them in separate cups and entered the resident's room. Agency LVN A then filled a plastic cup with water from the bathroom sink. She then retrieved a 60-cc piston syringe and drew up 50 cc of water and placed the feeding pump on hold. She disconnected the feeding tube from the G-tube and placed the water filled piston syringe into the G-tube connector and pushed 50 cc of water into the G-Tube. Agency LVN A then removed the piston syringe from the G-Tube and drew up some additional water and placed approximately 5 cc of water into each of the four medication cups and used the end of the plunger to stir the medications. She then removed the plunger from the piston syringe and reconnected the syringe into the G-Tube and administered each medication by gravity with 5 ml of water in between. Agency LVN A then refilled the piston syringe with 50 ml of water, reconnected to the G-Tube and pushed the water flush into the G-tube. She then reconnected the feeding tube and turned the pump back on. Removed gloves and performed hand hygiene. In an interview with Agency LVN A on 06/20/23 at 11:30 a.m., she stated this was her first day at this facility. She stated she normally worked in the hospital setting and stated the techs usually did the FSBS. She stated she was not sure when she was supposed to clean the glucometer and was unaware, she had to change her gloves and sanitized her hands after doing the FSBS. She stated she was not aware the Insulin pen had to be primed prior to dialing up the required amount of Insulin. When asked if the facility provided her with access to their policies she looked over at the desk and stated there was book for Agency staff with policies but stated she had not looked at it. When asked why she only used 50 ml of water instead of 60 ml she stated she was counting the flushes between medications as part of the required flush. She stated she had to push the water flushes because it would not flow by gravity. She stating she assumed it was because the G-tube was so small. She stated she was unaware there could be consequence for pushing the water. In an interview with the ADON on 06/20/23 at 12:00 p.m., she stated they tried to use the same agency nurses when they can. She stated they can go online and pull the agency staff members credentials and the training they had. She stated at any time, the staff member can come to her or the DON if they are uncertain or unsure how to perform a procedure. She stated they had a policy manual at the desk for the Agency staff to reference if they were unsure of a procedure. Record review of Agency LVN A's credentials provided by the staffing agency reflected her license was valid and current through 10/31/24 and she had passed Medical/Surgical facility assessments. There were no details listed of what was included in the Med/Surg assessment. In an interview with the Interim DON on 06/22/23 at 11:45 a.m., she stated staff were to prime the Insulin pens first to ensure they removed the air and to make sure the resident gets the required amount of Insulin. She stated at no time were staff to push water or medications into a G-tube. She 455806 Page 11 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated it was always supposed to be by gravity. She stated by pushing you could rupture the tube which would allow water or meds to spill into the abdominal cavity or could cause discomfort to the resident's stomach. Review of manufacturer's instructions obtained from https://www.humalog.com and searched on 06/23/23 reflected, .Prime before each injection. Priming your Pen means removing the air from the needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your pen with Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up and push the dose know in until it stops, and 0 is seen in Dose Window. Hold the dose know in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps . Review of the facility's policy and procedures, Medication-Administration .Insulin Pen dated November 2021, reflected, .Priming the Pen. Remove the outer needle cap and dial 2 units. Point the pen up and press the plunger button to expel 2 units of insulin. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. NOTE: A new pen may have to be primed up to 6 times before it will expel insulin . Review of [NAME] Potter's Nursing Interventions & Skills, 4th edition, 2007, pages 388 through 390, reflected, . Compare MAR with scheduled medication list or physician orders .Flush tubing .Administer medication. Pour first dissolved medication into syringe and allow to flow by gravity into feeding tube. If only one dose of medication is given, flush with 30 to 60 cc of water . Review of the facility's Policy and Procedures titled, Gastrostomy Tubes, dated May 2023, reflected, .The patient /resident that is fed by enteral methods receives the appropriate treatment and services to restore oral eating skills and prevent complications of enteral feeding like aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal /pharyngeal ulcers. 455806 Page 12 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for one (06/21/23 lunch) of one meal observed for food temperatures. The facility failed to ensure pureed ham was served at minimum of 145 degrees F and cabbage was served at least 135 degrees F for 06/21/23 lunch for residents with pureed diet. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 06/21/23 at 11:30 AM revealed Dietary [NAME] I took food temperature of pureed cabbage which revealed it was 122 degrees F. At 11:32 AM Dietary [NAME] I took food temperature of pureed ham of 120 degrees F. Interview on 06/21/23 at 11:35 AM with Dietary [NAME] I revealed ham food temperature needed to be at least 120 degrees F to 145 degrees F before serving. She stated vegetables, like cabbage, should have been 115 to 120 degrees F before serving. Observation on 06/21/23 at 11:48 AM revealed Dietary [NAME] I started plating food and pureed food of ham and cabbage on the steam table to be served. Dietary [NAME] I did not reheat or take temperatures of pureed ham and cabbage prior to serving for lunch. Observation on 06/21/23 at 12:22 PM revealed the last resident's lunch tray was served at 12:22 PM. Observation on 06/21/23 at 12:24 of pureed test tray revealed pureed ham was temped at 100.9 degrees F and tasted slightly cold. Pureed cabbage tasted cold. Interview on 06/21/23 at 12:48 PM with Consultant Registered Dietitian revealed the vegetables should have been at a minimum of 140 degrees F. She stated the pureed ham and cabbage should have been re-heated and re-temped prior to serving. Interview on 06/21/12 at 12:50 PM with Dietary [NAME] I revealed she had only been working at the facility for about 3 months and was still learning so she did not realize the pureed cabbage and ham were not at proper temperatures that required re-heating. Interview on 06/21/23 at 1:01 PM with Consultant Registered Dietitian revealed when hot foods were not served at appropriate food temperatures it could place residents at risk for bacterial growth in food and can affect the flavor of the food. Interview on 06/21/23 at 1:03 PM with the Dietary Manager revealed when residents received food at lower temperatures than required for hot foods, it placed residents at risk for pathogens. She stated they would in-service the dietary aide and staff to ensure they know the proper food temperatures when serving food to residents. Review of food temperature log for lunch on 06/21/23 revealed puree meat was recorded at 120 F and 455806 Page 13 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0812 puree vegetable was 122 F degrees. Level of Harm - Minimal harm or potential for actual harm Review of facility's in-service Food temp dated 02/24/23 did not reflect Dietary Aide was in-serviced about food temperatures. Residents Affected - Some Review of facility's policy Safe Food Temperatures revised 08/01/2020 reflected Food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery .Minimum safe internal cooking temperatures for some high-protein foods that require special handing are as follows: B.Whole cuts of meat (beef, pork, ham, steaks, and chops .Cook whole cuts or meat to at least 145 degrees F internal cooking temperature then allow it to rest 3 minutes before carving or consuming .6. Hold hot foods at 135 F or higher during meal service (on the trayline). 7. Check and record trayline food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165 F for 15 seconds (for hot foods) or discard it. 455806 Page 14 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

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 Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #15) of five residents observed for infection control in that: Residents Affected - Few 1. The facility failed to ensure Agency LVN A performed hand hygiene after completion of FSBS 2. The facility failed to ensure Agency LVN A failed to sanitize the glucometer prior to and after obtaining FSBS on Resident #15. Theses failure could place residents at risk for infection and cross contamination. Findings included: Review of Resident #15's undated Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus. Review of Resident #15's Physician Orders Report dated 06/01/23 to 06/30/23 reflected, . FSBS AC &HS with Humalog SQ sliding scale as follows .151 to 200 = 3 Units . An observation on 06/20/23 at 11:00 a.m. of the medication pass revealed Agency LVN A picked up the un-sanitized glucometer from the top of the medication cart and retrieved supplies and entered Resident #15's Agency LVN A pricked the resident's finger and obtained a FSBS reading of 161. Agency LVN A returned to the medication cart and disposed of the lancet and test strip and placed the glucometer on top of the medication cart. Agency LVN A, still wearing soiled gloves, looked at the MAR and determined resident would need insulin according to sliding scale and opened the medication cart and sorted through the various insulin pens in the drawer and stated she would have to go to the medication room, since there was not an insulin pen on the cart for Resident #15. Agency LVN A removed her gloves and without performing hand hygiene, went to the medication room and searched the refrigerator looking through multiple insulin pens but could not find a pen for Resident #15. Agency LVN A reported to the Interim DON of the need for an Insulin Pen out of the emergency kit and then returned to the medication cart to proceed with her next medication pass. An observation on 06/20/23 at 11:25 a.m. revealed a staff member delivered a new Humalog Insulin pen to Agency LVN A to be used for Resident #15. Agency LVN A picked up the un-sanitized glucometer to recheck the resident previous blood sugar readings and determined it was 161. Agency LVN A put on gloves without performing hand hygiene, placed a needle on the insulin pen and dialed 3 units without priming the pen first. Agency LVN A then administered the Insulin to Resident #15, disposed the needle, removed her gloves and without performing hand hygiene placed the pen and the un-sanitized glucometer back into the medication cart. In an interview with Agency LVN A on 06/20/23 at 11:30 a.m., she stated this was her first day at this facility. She stated she normally worked in the hospital setting and stated she did not do FSBS. She stated she was not sure when she was supposed to clean the glucometer and was unaware, she had to change her gloves and sanitize her hands after doing the FSBS. When asked if the facility provided her with access to their policies she looked over at the desk and stated there was book for Agency 455806 Page 15 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0880 staff with policies but stated she had not looked at it. Level of Harm - Minimal harm or potential for actual harm In an interview with the Interim DON on 06/22/23 at 11:50 a.m. she stated staff were to change their gloves and perform hand hygiene after any procedure and stated the glucometer was to be sanitized before and after each use. She stated failure to do this placed resident at risk of blood borne pathogens as well as infections. Residents Affected - Few Review of the facility's policy titled, Hand Hygiene/ handwashing, dated November 2017, reflected, Hand hygiene/hand washing is done before patient/resident contact .Before taking part in a medical or surgical procedure .After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids .After contact with a contaminated object or source where there is a concentration of microorganisms .After removal of medical/surgical or utility gloves . Review of the facility's policy and procedure titled, Blood Glucose monitoring, dated October 2017, reflected, .Wash hands and put on disposable gloves .Follow manufacturer guidelines for Blood glucose Monitoring .discard lancet in sharps container .Remove gloves and wash hands .Document results in MAR .Clean Glucometer utilizing 2-step process with approved EPA disinfectant wipe which is labeled effectives against TB or HBV, HCV ,and HIV to remove any visible contaminants, soil or other debris. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time . 455806 Page 16 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the dining room and one of four halls (Hall 3) reviewed for pest control. Residents Affected - Some The facility failed to keep an effective pest control program to ensure the dining room, kitchen, and residents' rooms on Hall 3 were free of flies and gnats. This failure could place residents at risk for a reduced quality of life. Findings included: Observation on 06/20/23 at 10:09 AM revealed three flies on Resident #11's bed and 1 fly landed on her pillow. Interview with Resident # 11 revealed the flies bothered her and she used to have a fly swatter in her room, but someone took it. She stated she would swat at them all the time. Resident #11 stated the flies were constantly in her room on a daily basis and at least the last month the flies had gotten worse. Observation and interview on 06/20/23 at 10:12 AM revealed Resident # 16 stated he had flies in his room. Observed 2 flies in the resident room. Observation on 06/20/23 at 12:25 PM revealed about four flies in dining room while residents ate lunch and two flies landed on residents' plates. Interview on 06/20/23 at 12:38 PM with CNA J revealed the flies and gnats had been getting worse for the last couple of months. She stated on the hallways, there were electronic bug zappers to help with the flies but were taken down by Maintenance due to ongoing painting of the walls in the resident hallways for the last couple of months. She had a fly swatter in her hand to help get rid of the flies. Observation and Interview on 06/20/23 at 12:42 PM with Resident # 24 revealed the flies were bad in facility and in her room since Spring. She stated they only had fly traps in dining room. Observation in Resident # 24's room revealed two flies near her lunch tray and one landed on her plate while she was eating her food. She shoed the flies away with her hand. Observation and interview on 06/21/23 at 09:10 AM in Resident #8's room revealed a paper cup with yellowish liquid in it. 4 gnats were around the paper cup. Resident # 8 stated the flies and gnats were worse since it was getting warmer outside for the last couple of months. She stated they bothered her. She stated she was not drinking out of that paper cup anymore. Observation on 06/21/23 at 9:15 AM revealed Agency LVN H poured out the cup in bathroom sink and threw the paper cup in the trash. He stated he had noticed the gnats and flies in the facility but this was first week at the facility. A Confidential Group Interview on 06/21/23 at 11:00 AM revealed 2 of 7 residents stated they had issues with flies and gnats in their rooms and in dining rooms. Observation on 06/21/23 at 11:57 AM in dining room during lunch revealed three flies flying around 455806 Page 17 of 18 455806 06/22/2023 The Terrace at Denison 1300 Memorial Dr Denison, TX 75020

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some near steam table while Dietary Aide plated food. Two flies landed on a resident table while residents were drinking their teas. Interview on 06/22/23 at 10:55 AM with the Maintenance Director revealed he had been painting the halls for at least the last month on and off. He took the bug zappers down since he was painting. He had not put them back up since he was still painting. He stated the bug zappers helped with catching flies and gnats. He stated pest control came out monthly to treat for the flies. Interview on 06/22/23 at 11:45 AM with the Administrator revealed the facility paid extra to treat large flies on a monthly basis . She stated she would have the Maintenance Director put up the bug zappers back on the hall to assist with flies and gnats. Review of facility's policy Pest Control dated 08/01/2020 reflected Facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. 455806 Page 18 of 18