Health inspection·March 28, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 2 of 17 residents (Residents #23, and #47) reviewed for transfers, in that: The facility did not provide Resident #23 and Resident #47 with a written bed-hold policy when the residents were transferred out to the hospital or were on therapeutic leave. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions. The findings were: Record review of Resident #23's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include spinal stenosis (narrowing of the spinal canal), and constipation. Record review of Resident #23's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record Review of Resident #23's census from the EMR revealed that on 06/09/23, 07/07/23 and 07/24/23 he was on therapeutic leave. On 07/27/23 billing was stopped. The DON indicated in writing on the document that he had went home to visit his family . Record review of Resident #23 admission record indicated that his representative received the bed-hold and readmission policy on 10/29/23 indicating that the facility procedure was upon transfer or discharge, review the bed hold policy with the resident/representative, either in person or via telephone communication. Record review of Resident #47's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Schizoaffective disorder (a combination of mood disorder and schizophrenia), anxiety disorder (increased worry), and intermittent explosive Page 1 of 25 455936 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0625 disorder (mental disorder that include outbursts). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #47's Comprehensive Minimum Data Set, dated [DATE], revealed: Residents Affected - Many Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record Review of Resident #47's census from the EMR revealed that on 02/09/24 and 03/16/24 billing was stopped. The DON indicated in writing on the document that both dates he had discharged to a behavioral hospital. Record review of Resident #47's admission record indicated that he received the bed hold and readmission policy on 01/09/24 indicating that the facility procedure was upon transfer or discharge, review the bed hold policy with the resident/representative, either in person or via telephone communication. During an interview on 03/27/24 at 09:16 AM, the DON said they did not do bed holds, and their company had never had them do bed holds for transfers. She said they did not give anything to the residents when they were transferred out. During an interview on 03/27/24 at 11:50 AM, the DON stated that she was unaware of the facility's bed hold policy. She said she did not feel that there was a potentially negative outcome because they always had beds available. She said they did not have a system for issuing written notice of bed holds. She said she had not been trained on the facility bed hold policy. She said her expectation of the bed hold policy was that she be trained but that the facility policy be followed. She said the Director of Resident Accounts would be responsible for the bed holds. She stated that other than the Director of Resident Accounts, she believed other charge nurses would be responsible. She said she was unaware of the two residents (resident #23 and Resident #47) who did not receive notice of the facility bed hold during their leave. During an interview on 03/27/24 at 12:00 PM, the ADM stated the potential negative outcome of not following the bed hold policy was if the facility were at capacity, the risk would be for residents who go out on leave or the hospital would not have a bed (if they returned). She said she did not feel that was an issue because they were far from being at full capacity, so essentially, there was no potential negative outcome. She said the purpose of the bed hold policy was to let residents know their rights about holding their bed if needed. She said she was unaware that the two residents had not received written notification of the bed hold policy. She said she expected training to be implemented regarding the bed hold policy and that all facility policies would be followed. She said the Director of Resident Accounts and herself would be responsible, as would nursing staff if it was a weekend or holiday. During an interview on 03/27/24 at 12:15 PM, the Director of Resident Accounts stated she was unaware that the two ( Resident #23 and Resident #47) residents identified had not received written notice and that they all had received a copy of the bed hold policy upon admission. She said at admission, they let the resident know that if they were at full capacity and go out on pass, they could potentially lose their room. She said the resident's signature on the bed hold policy at admission held their room. She said there was no specific number of days that the room was held for, but that their system to monitor was that they signed the bed holds policy at admission and that they held their bed. She said she was responsible for the bed hold agreement but had never been trained to give it to 455936 Page 2 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the residents outside of admission. She said she only expected the bed hold agreement to be provided during admission. During an interview on 03/28/24 at 11:58 AM, Resident #23 stated that he had never received anything about the bed hold policy when he left and went with his family if he had been to the hospital. He said he did not understand what it was and did not want to pay anything extra if he did not have to. He said he did not know anything about the facility policy. He said he did not know if he received anything during admission because his family helped with all the paperwork. Record review of the facility policy, Bed Hold Reservation Agreement (undated) revealed, 483.15 (d) (I) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifiesThe duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence at the nursing facility; The reserve bed payment policy in the state plan under 447.40 of this chapter, if any; The nursing facility policies regarding bed hold periods, which must be consistent with paragraph Euro (I) of this section, permitting a resident to return; and The information specified in paragraph Euro(I) of this section. 483.15 (d)(2) Bed- hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed hold policy described in paragraph (d) (I) of this section. Policy It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Additionally, this facility permits residents to return to the facility after hospitalization or therapeutic leave if their needs can be met by the facility, they require the services provided by the facility and they are eligible for Medicaid or Medicare covered services or services covered by another payor. Residents and their representative will be provided with a bed hold and return information at admission and before a hospital transfer or therapeutic leave. Nursing and social work staff are educated about the resident's bed hold and return rights to ensure that required information is provided at the time the resident leave the facility. 455936 Page 3 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, observations and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 7 of 17 residents (Residents #12, #14, #23, #28, #40, #44 and #47) reviewed for care plans as follows: Resident #12 did not have a care plan for urinary incontinence. Resident #14 did not have a care plan for urinary incontinence. Resident #23 did not have a care plan for urinary incontinence. Resident #28 did not have a care plan for urinary and dehydration. Resident #40 did not have a care plan for cognitive loss, vision, communication, urinary incontinence, and dental care. Resident #44 did not have a care plan for falls. Resident #47 did not have a care plan for cognitive loss. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include : Record review of Resident #12's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include hypothyroidism (underactive thyroid), and diabetes (high blood sugar). Record review of Resident #12's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence Section H Bowel and Bladder revealed Resident #12 was occasionally incontinent of urine. Record review of the Resident #12's care plan dated 03/5/24 did not reveal a care plan for urinary incontinence. Record review of Resident #14's face sheet, dated 03/26/24, revealed a [AGE] year-old-female was 455936 Page 4 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on [DATE] with diagnoses to include difficulty walking, reduced mobility and overactive bladder. Record review of Resident #14's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence Section H Bowel and Bladder revealed Resident #14 was occasionally incontinent of urine. Record review of the Resident #14's care plan dated 11/14/23 did not reveal a care plan for urinary incontinence. Record review of Resident #23's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include spinal stenosis (narrowing of the spinal canal), and constipation. Record review of Resident #23's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence Section H Bladder and Bowel revealed that Resident #23 was always incontinent of urine. Record review of Resident #23's care plan, dated 03/05/24, revealed no care plan for urinary incontinence. Record review of Resident #28's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dehydration, cognitive communication deficit, diabetes (low blood sugar), dementia (memory loss), difficulty walking and muscle weakness). Record review of Resident #28's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: 455936 Page 5 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0656 CAA Results: Level of Harm - Minimal harm or potential for actual harm 06. Urinary Incontinence 14. Dehydration Residents Affected - Some Section H revealed that Resident #28 was occasionally incontinent of the urine. Record review of Resident #28's care plan, dated 02/19/24, revealed no care plan for urinary incontinence and dehydration. Record review of Resident #40's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include reduced mobility, need for assistance with personal care, constipation, muscle weakness, cognitive communication deficit, absence of right and left leg below the knee. Record review of Resident #40's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 02. cognitive loss 03. Vision 4. Communication 06. Urinary Incontinence 15. Dental Care Section B Hearing, Speech and vision revealed that Resident #40 had minimal difficulty in hearing, and he was usually easily understood and understood others. His vision was impaired, and he required corrective lenses. Section H Bladder and Bowel revealed that Resident #40 was occasionally incontinent of urine. Section L revealed that Resident #40 had broken or loosely fitting full or partial dentures. Record review of Resident #40's care plan, dated 03/05/24, revealed no care plan for cognitive loss, vision, communication, urinary incontinence and dental care. Record review of Resident #44's face sheet, dated 03/26/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), muscle weakness, unsteadiness on feet, and lack of coordination. 455936 Page 6 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0656 Record review of Resident #44's Comprehensive Minimum Data Set, dated [DATE], revealed: Level of Harm - Minimal harm or potential for actual harm Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Residents Affected - Some Section V Care Area Assessment (CAA) Summary: CAA Results: 11. Falls Section J Health conditions revealed no history of falls. Record review of Resident #44's care plan, dated 03/26/24 revealed no care plan for falls. Record review of an email dated 04/01/24 at 1:44 PM from the ADM and Regional MDS Coordinator revealed Resident #44 triggered for falls because wandering occurred and she had balance problems during transition. Record review of Resident #47's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Schizoaffective disorder (a combination of mood disorder and schizophrenia), anxiety disorder (increased worry), and intermittent explosive disorder (mental disorder that include outbursts). Record review of Resident #47's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 02. Cognitive Loss Record review of Resident #47's care plan, dated 02/06/24, revealed no care plan for cognitive loss. Record review of an email dated 04/01/24 at 1:44 PM from the ADM and Regional MDS Coordinator revealed Resident #47 triggered for cognitive loss because staff assessment or clinical record suggested presence of inattention, disorganized thinking, altered level of consciousness. During an interview on 03/27/24 at 10:35 AM, the Regional MDS Coordinator stated that if the care plan reflected resolved, the resident had that issue at some point but no longer had the identified problem. During an interview on 03/27/24 at 11:03 AM, Resident #44 stated she had not had any falls and had not participated in care plan meetings. She said she had not fallen before, and staff were not making any special efforts to ensure that she did not fall that she knew of . 455936 Page 7 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/27/24 at 11:05 AM, Resident #23 stated that he wore a brief regularly. He said he could not change himself because he could not use his arms. He said he did not participate in his care plan meeting because he had chose not to. During an interview and observation on 03/27/24 at 11:08 AM, Resident #28 stated that he used his urinal every night because it was easier and more convenient. He said he wore briefs periodically to help with accidents. He said he drank plenty of water all the time. He said he had been talked to about care plan meetings but had not remembered attending one. An empty urinal was observed on Resident #28's bedside table. An opened package of adult briefs was also observed on the floor beneath Resident #28's bed. During an interview and observation on 03/27/24 at 11:12 AM, Resident #40 stated that he wore glasses to be able to see. He said although he spoke and understood English, he preferred speaking Spanish. He said depending on how big the English word was would determine whether he understood it. He said he wore a brief and required the assistance of staff. He said if he was assisted, he could not complete his ADLs. He said he needed to go to the dentist. He was not in pain but had 4 teeth that needed to be pulled . He said he does not remember ever participating in a care plan meeting. A pair of glasses was observed on Resident #40's shirt. During an interview on 03/27/24 at 11:14 AM, Resident #14 stated that she had participated in a care plan meeting in another facility but not in the current facility. She said she did not know when the facility had care plan meetings. She said she wore briefs and required staff assistance to change her. She said she could help staff a little bit but not much. During an interview on 03/27/24 at 11:18 AM, Resident #12 stated that he did wear a brief and requires help from staff. During an interview on 03/27/24 at 11:31 AM, the Regional MDS Coordinator stated that a care plan identified residents' needs and issues that residents might have. She said they used the RAI manual to complete the MDS. She said the items triggered in Section V of the MDS should be care planned. She stated that if the triggered item was not an issue, the items do not have to be care planned . She said sometimes information was inaccurate, and interviews with the person completing the MDS, staff, and residents would help identify those inaccuracies. She said a potential negative outcome of inaccurate care plans could be missed documentation. She said she was unaware of any missing care plans. She said that, of the care plans identified as missing, she did not see a significant issue because the missing items were addressed in interventions for other care plans. She said she agreed that the problem, goals, and interventions should be consistent with one another. She said the system to monitor care plans was that they conduct quarterly care plans and reviews and do weekly care plan meetings. She said they also conduct weekly risk meetings to review care plans. She said she also performed audits periodically. She said the facility person assigned to complete care plans was the MDS Coordinator. She said she (the MDS Coordinator) was out with her ill family member and was not at the facility. She said she had been trained on how to complete care plans, and so had the MDS Coordinator. During an interview on 03/27/24 at 11:41 AM, the DON stated that the care plan was a plan that provides all nursing staff with a plan of care for each resident. She said the potential negative outcome of missing or inaccurate care plans was the resident could receive subpar treatment, and confusion could be caused among staff. She said it could potentially cause poor care for the resident. She said she was unaware that any residents were missing care plans. She said she had not received any 455936 Page 8 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reports about issues with care plans. She said the care plan should start with the CAAs from Section V. She and her nursing staff care planned for acute problems, and the MDS Coordinator would care plan for the CAAs. She said she expected all care plans to be accurate. She said they do not have to include all triggered areas CAAs, but the MDS would reflect whether they were care planned. She used Resident #28 as an example. She said in his case, at one time, Resident #28 had diarrhea, and due to the diarrhea, he became dehydrated. She said it would be an accurate coding but unnecessary for the care plan. When asked if she knew he was using the urinal every night, she said she was. When asked if she knew he wore adult briefs, she said she was unaware of that information. She said she had been trained to complete accurate care plans. She said she was responsible for ensuring that care plans were complete and accurate. She said she oversaw the MDS Coordinator. She said that as it relates to resolved care plans, those care plans have been fixed and were no longer needed. She said nurses can see resolved care plans, but CNAs cannot. During an interview on 03/27/24 at 11:47 AM, the ADM stated that the potential negative outcome of inaccurate or incomplete care plans was that residents could receive inappropriate care. She said the purpose of the care plan was to ensure all needs of the residents were being met. She said all staff used the care plan. She said she was unaware that any residents were missing any care plans. She said the system to monitor care plans was the MDS Coordinator. She said she knows that there were audits conducted, but she was unsure of the schedule and outcome of the audits. She said she had not been trained regarding the completion of the care plan. She said she expected care plans to be completed accurately and meet the needs of the resident. She said the MDS coordinator was responsible for completing care plans. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023, revealed the following: an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Record review of the facility policy, Care Plan Expectation (undated), revealed the following: Accountability for care planning is as follows: The DON is responsible for ensuring care plans are completed timely and are reflective of each resident. The MDS Coordinator and IDT will be responsible for any care plans triggered by the MDS/CAAs Licensed nurses will be responsible for the acute care plans such as falls, infections . 455936 Page 9 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 1 treatment cart observed for drug storage. The facility failed to ensure LVN B did not leave wound cleanser on top of the treatment cart unsupervised. This failure could place residents at risk of harm due to misuse or accidental ingestion. ,. The findings were: Record review Resident #12's face sheet dated 03/26/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stroke, diabetes (high blood sugar), dementia (cognitive loss), hypertension (high blood pressure), and major depressive disorder (mental illness, feeling of sadness). Record review of Resident #12's quarterly MDS assessment, dated 02/20/24 revealed a BIMS score of 13, which indicated cognition was intact. Section M - skin conditions reflected Resident #12 had application of nonsurgical dressings and ointments/medications. Record review of Resident #12's care plan dated 02/09/24 reflected a focus area Resident #12 had wound to his left bka (below knee amputation) stump, with interventions to perform treatments per MD orders. Record review of Resident #12's physician's orders dated 03/26/24 reflected wound care to stump wound every day as follows: Cleanse with wound cleanser or NS, pat dry with 4x4 gauze, apply Thera-honey to wound bed and then xeroform, cover with foam or dry dressing. Order dated 03/05/24. Record review of the wound cleanser spray bottle label undated reflected Warnings: Keep out of reach of children. For external use only. Do not use in the eyes. If swallowed, get medical help or contact a Poison Control Center immediately. During an observation and interview on 03/27/24 at 09:00 AM LVN B prepared wound care supplies outside of Resident #12's room. She placed 4x4 gauze in a cup and sprayed it with wound cleanser. She placed the wound cleanser spray bottle on top of the treatment cart. She gathered the supplies and entered Resident #12's room. She closed the resident's door and pulled the privacy curtain. The treatment cart remained outside of Resident #12 room. After completing wound care LVN B went to the treatment cart and pushed treatment the cart to the nurse's station. The wound cleanser spray bottle remained on top of the treatment cart. LVN A took the treatment cart down to hall 300 to room [ROOM NUMBER]. LVN A prepared wound supplies for a resident and before gathering supplies placed the wound cleanser spray bottle in treatment cart. During an interview on 03/28/24 at 11:00 AM with LVN B, she stated the wound cleanser spray bottle should have been placed back inside the treatment cart before she left the treatment cart 455936 Page 10 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0761 Level of Harm - Minimal harm or potential for actual harm unattended. She stated there was no reason she left it on top of the cart. She stated she had been trained to keep all supplies and medications always locked when the cart was unattended. She stated the wound cleanser spray bottle had a warning to keep out of reach of children and if swallowed to get medical help. She stated the potential negative outcome could be a resident getting the bottle and drinking it. She stated the wound cleanser could cause resident harm. Residents Affected - Few During an interview on 03/27/24 at 03:00 PM with the DON, she stated the wound cleanser spray bottle should not be left on top of the treatment cart unattended. She stated all staff had been trained on medication and supply storage. She stated the potential negative outcome could be a resident drinking the solution causing diarrhea or an upset stomach. During an interview on 03/28/24 at 09:00 AM with the ADM, she stated the wound cleanser spray bottle should not be left out on top of the medication cart unsupervised. She stated staff had been trained on proper storage of supplies and medications. She stated the ADON and DON were responsible for monitoring for compliance. She stated the potential negative outcome could be a resident could get it and ingest it. Record review of the facility's policy titled Storage of Medications, dated 09-2018 reflected the following: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. General Guidance . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . 455936 Page 11 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food was accurately dated and labeled. The facility failed to protect foods from potential contamination. Foods were not handled in a manner to prevent contamination. Food contact equipment and other equipment was not maintained in a clean manner. Foods were not stored according to manufacturer's recommendation. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation on 03/26/24 at 09:34 AM, revealed concord grape jelly, dated 02/26/24, was on the dry pantry shelf. More than 75% of the jelly was gone. The label on the back of the jar reflected, Refrigerate after opening. Observation on 03/26/24 at 9:41 AM, revealed unlabeled and undated pancakes and toast in the microwave. Observation on 03/26/24 at 09:25 AM, revealed opened box coffee concentrate in the broken coffee machine without a lid. Observation on 03/26/24 at 09:25 AM, revealed a uncovered jar of oil and butter on the stove. Further observation revealed the butter was not actively used until 12:07 PM when the Food Service Manager put butter on the rolls. The butter and oil remained uncovered for the duration of the day. Observation on 03/26/24 at 09:25 AM, revealed unknown food particles and an unidentifiable crust on the stove's cooking range. Observation on 03/26/24, at 09:26 AM, revealed unknown food particles were along the underside of both oven doors. Observation on 03/26/24, at 09:30 AM, revealed unknown food particles, grease, paper, and plastic were alongside the left side of the griddle. Observation on 03/26/24 at 11:21 AM, revealed 2 uncovered chocolate pudding desserts were under another tray of pudding desserts, exposing the two uncovered pudding desserts to the bottom of the tray. Observation on 03/26/24, at 11:26 AM, revealed the DM placed uncovered pureed zucchini in the oven 455936 Page 12 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many under a pan of fried chicken, exposing the pureed zucchini to the bottom of the tray that held the fried chicken. Observation on 03/26/24, at 11:20 AM, revealed 37 uncovered drinks. At 11:35 AM, the Food Service Aide placed ice in the drinks but did not cover the drinks afterwards At 11:48 AM, the Food Service Aide only covered 2/37 drinks with lids, leaving the other 35 drinks uncovered. At 11:52 AM, the Food Service Aide reached over the uncovered cups to grab an item. At 12:04 AM, the Food Service Aide covered 33 of the 35 remaining uncovered drinks, leaving two drinks still uncovered. The two drinks remained uncovered until placed in the fridge at 12:15 PM. Observation on 03/26/24, at 12:07 PM, revealed a large bowl of salad that contained fresh tomatoes and cumbers and was placed on the steam table in between hot foods, not on ice The uniced salad remained on the steam table between hot foods until 12:49 PM when the Food Service Manager served the last tray. Observation on 03/27/24, at 06:54 AM, revealed concord jelly, dated 03/25/24, was on the dry pantry shelf. More than 25% of the jelly was gone. The jar label reflected, Refrigerate after opening. Observation on 03/27/24, at 06:55 AM, revealed an uncovered jar of oil and butter on the stove. Observation on 03/27/24, at 06:59 AM, unknown food particles and an unidentifiable crust were observed on the stove's cooking range. Observation on 03/27/24, at 07:00 AM, revealed unknown food particles were along the underside of both oven doors. Observation on 03/27/24, at 07:01 AM, revealed unknown food particles, grease, paper, and plastic were alongside the left side of the grill. Observation on 03/27/24, at 7:08 AM, revealed 25 unlabeled, undated peanut butter and jelly sandwiches on the bottom shelf of a metal rack. Observation on 03/27/24, at 7:10 AM, revealed a sprinkler head in the ceiling to the right of the stove with dust and unknown debris. During an interview on 03/28/24 at 09:08 AM, the Food Service Aide stated that the food was in the microwave undated and unlabeled because it was meant for the DM, and he had yet to get it. She said the potential negative outcome for uncovered food was things could fall in it, and then the residents at the facility could get it. She said she was not aware that the items identified were uncovered. She said she was busy trying to get her work done. She said food should be covered immediately if not being actively served. She said she was aware that the two desserts were not covered but only noticed when they removed the tray on top of it. She then immediately placed the lids on the desserts. She said she was aware that the juices were not covered. She said the manager was responsible for covering the food when it was not being served. She said that regarding the dirty equipment (stove/oven), including the dirty sprinkler head, residents could get sick if they were using dirty equipment. She said she was unaware if the dirty equipment included the sprinkler head. She said the DM was strict about keeping things clean and did not know why the stove or the sprinkler head was not clean. She said items that were to be refrigerated could potentially spoil and make residents sick. She said she knew the jelly was on the shelf in the dry pantry but did not know she needed to refrigerate 455936 Page 13 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many it. She said they labeled the food but did not read the label stating the food item required to be refrigerated after it had been opened. She said they were all responsible for putting food items that needed refrigeration in the refrigerator. She said placing cold foods on ice could prevent food from spoiling, or the food that was supposed to be served cold would be served hot, and residents would not like it. She said residents would not like hot salad. She said she knew the salad was not on ice, and she believed that was how they usually served it. She said she had been trained to place cold items with fresh vegetables and anything with egg or milk on ice. She said she would have been responsible for putting the food items on ice, but they all could do it. She said the potential negative outcome for unlabeled or undated food was that people might not know when it was prepared and that old food could be given to the residents. She said she did not work overnight but believed that was where the sandwiches came from. She said that she was aware that the sandwiches were there. She said she had been trained to date and label all food. She said they placed the date received, opened, and knew to dispose of it three days after it had been opened. She said all of them were responsible for dating and labeling food. During an interview on 03/28/24 at 09:27 AM, the Food Service Manager stated that the potential negative outcome of uncovered food was debris that could get in the food. She said she knew there were some uncovered items but did not know they were supposed to be covered. She said that they did not have a system for covering food. She said she had been trained to cover food if placed in the refrigerator but not if they placed food in the oven. She agreed that the uncovered items in the oven could have things fall in it if they were placed directly under a pan. She said she was unaware that the sprinkler head in the kitchen needed to be cleaned. She said she rarely looked at the sprinkler head. She said she was aware of the stove being dirty on the side, but it was difficult to clean that portion of the stove. She said that using dirty equipment could contaminate the resident's food. She said their system was to clean after each meal. She said they should immediately clean up spills and the oven range and underneath weekly. She said she cleaned the eyes of the stove on 03/27/24 but did not have a reason why it was not clean as of 03/26/24. She said everyone was responsible for cleaning kitchen equipment. She said the potential negative outcome of not refrigerating appropriate food items was it could cause disease to grow in the food, be served to the residents, and then make them sick. She said she was aware that the jelly label said to refrigerate after opening it but that she would put the jelly in the refrigerator and then put it on the shelf. She said the system for monitoring was they should place it in the fridge each time they saw it. She said everyone was responsible. She said the potential for not putting the salad on ice was that bacteria could grow, and residents could have received warm salad. She said she knew the salad was not on ice and that she was serving from the steam table. She said it was placed on the steam table for convenience while serving. She said they were all responsible for putting the appropriate foods on ice. She said the potential negative outcome of not labeling or dating food was that a resident could be allergic to it if you did not know what it was. She said bacteria could grow because they don't know when it was prepared, and it could be served to the residents and make them sick. She said she was aware of the peanut butter and jelly sandwiches but was unaware that they were on the shelf and not labeled. She said she had been trained to label all food items. During an interview on 03/28/24 at 09:58 AM, the DM said the potential negative outcome for food being uncovered was that things could get into the food and potentially be served to the residents. She said she knew that food was uncovered, specifically the pureed food, which he placed in the oven himself. He said he was unaware of the other uncovered items. He said he did not have a system to ensure that food was covered until actively being served. Unless actively being served, he said he had been trained to 455936 Page 14 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many cover things and ensure there was a barrier over the food to ensure nothing fell in the food. He said he expected all food to be covered unless it was actively being served. He said he had been trained to ensure a barrier was protecting the food, especially if an item was over it. He said the potential negative outcome of dirty equipment was that it could infect the residents' food. He said it could cause cross-contamination. He said the potential negative outcome of a dirty sprinkler head was that debris could not fall off the sprinkler head and into the food and that the sprinkler might not function properly. He said he was unaware of the sprinkler head. He said they were not allowed to touch the sprinkler heads, and the fire department was responsible for those. He said the fire department did not like to come out. He said he should have called them. He said he was aware of the dirty stove and the debris on the right side of the stove that they could not reach to clean. He said he had been trained to clean all equipment in the kitchen. He said that he did have a cleaning schedule that they followed. He said if food was supposed to be refrigerated or not, then bacteria could grow inside. He said bacteria could make staff and residents sick. He said he was unaware that the jelly was on the shelf in the dry pantry. He said the system to monitor was everyone should be watching and placing the appropriate items in the fridge. He said that not placing appropriate food on ice, such as fresh vegetables, could cause the food items not to be cold and served warm and might not be palatable. He said he was unaware that the salad was not served on ice as he was not paying attention. He said the system was their policy and procedures. He said the cook was responsible for ensuring the appropriate foods, such as eggs, milk, and fresh vegetables, were placed on ice. He expected that all proper foods should be placed on ice while serving. He said the potential negative outcome of not labeling food was that staff might not know when the food was made and could go bad or be served to the residents. He said he saw them the morning of 03/28/24 and was aware that the snacks (sandwiches) were there because staff had told them they had failed to place the snacks out the night before. He said he did not know why he did not remove them as it slipped his mind. He said the system for monitoring was that once they receive food or make food, they label it immediately. He said he expected all foods should be labeled. He said he and his staff had all been trained in all the identified deficient practices. During an interview on 03/28/24 at 10:41 AM, the ADM stated that she was unaware that food was uncovered in the kitchen. She said they were unaware if there was a system for uncovered food in the kitchen. She said all dietary staff was responsible. She said she expected food to stay covered unless actively being served. She said the potential negative outcome of food not being covered was that food could become contaminated and served to the residents. She said the potential negative outcome of dirty equipment was it could make the residents sick because dirt or debris could get in the food. She said she had been in the kitchen the previous month and did not see any issues, but the dietary staff had also been doing deep cleaning and after-meal service. She said the dietary staff were responsible for cleaning all equipment. She said there was no reason for any dirty equipment but that she could observe the gunk alongside the stove and griddle. She said the DM told her that the dietary could not reach that part of the stove. She said that all the dietary staff was responsible for ensuring that the kitchen equipment was clean, and she expected all kitchen equipment to be cleaned. She said she was unaware of the jelly being opened and still on the dry shelf. She said the potential negative outcome was that there could be food poisoning. She said the dietary staff ensured that the appropriate foods were refrigerated. She said if the food that was supposed to be on ice was not on ice, then there was a potential for foodborne illness, and it might not taste as good. She said she was unaware that the dietary staff was serving salad without it being on ice. She said she expected all food that was to be served cold to be served cold. She said the 455936 Page 15 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0812 Level of Harm - Minimal harm or potential for actual harm dietary staff were responsible for ensuring that the appropriate foods were served on ice. She said the potential negative outcome for unlabeled and undated food was that residents could be served expired food, which could potentially make the residents sick. She said she expected all food to be labeled and dated. She said she was unaware of the sandwiches that were unlabeled and undated. She said the dietary staff was responsible for dating and labeling food. Residents Affected - Many Record review of the facility's cleaning schedule, dated March 2024, revealed the following: The cook was responsible for cleaning the oven to include the range and had been cleaned by the Food Service Manager daily until the 03/27/24. (No details to indicate the fire sprinkler) Record review of the U.S. Food and Drug Administration Food Code revealed: 3-305.14 Food Preparation During preparation, unpackaged food shall be protected from environmental sources of contamination. 3-307 Preventing Contamination from Other Sources FOOD shall be protected from contamination 3-602.11 Labeling Label information shall include: The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: At any time during the operation when contamination may have occurred Record review of the facility policy, Food Storage (dated 04/11/22) revealed: Policy All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws, and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness. Procedure Food removed from its original packaging will be labeled with the receive date, open date, and contents of the package. Cold foods to be served on the serving line will be put on a bed of ice to keep cold. 455936 Page 16 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

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 6 (Residents #1, #31, #38 and #45) and 2 of 2 (CNA C and CNA D) and 1 of 1 (LVN A) staff reviewed for infection control. Residents Affected - Some 1. CNA C failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #45. 2. CNA D failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #1. 3. LVN A failed to clean surface before placing wound supplies on surface while providing wound care to Resident #31 and Resident #38. These failures could place residents at risk for spread of infection and cross contamination. Findings include: 1. Resident #1 Record review Resident #1's face sheet dated 03/27/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included stroke, quadriplegia (paralysis of all 4 limbs) major depressive disorder (mental illness, feeling of sadness), hypertension (high blood pressure) and anxiety (feeling of fear). Record review of Resident #1's comprehensive MDS assessment, dated 10/16/23 reflected no BIMS score, staff assessment reflected severely impaired cognitive skills for daily decision making. Resident #1 was dependent on staff for toileting hygiene, and personal hygiene. Record review of Resident #1's care plan dated 03/05/24 reflected a focus area which indicated Resident #1 had an ADL self-care performance deficit r/t disease processes with interventions that Resident #1 was totally dependent on staff for personal hygiene and toilet use. Resident #31 Record review of Resident #31's face sheet dated 03/27/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stoke, major depressive disorder (mental illness, feeling of sadness), hemiplegia (paralysis) left side, pressure ulcer, diabetes (high blood sugar), and hypertension (high blood pressure). Record review of Resident #31's comprehensive MDS assessment, dated 01/10/24 reflected a BIMS of 00 which indicated severely impaired cognition. Resident #31 had pressure ulcer injury and care and was at risk for pressure ulcers. Record review of Resident #31's care plan dated 02/19/24 reflected a focus area which indicated Resident #31 had an unstageable pressure injury to the left heel with interventions to administer 455936 Page 17 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0880 treatments as ordered. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #31's physician's orders dated 03/27/24 reflected an order dated 03/13/24 for wound care to the left heel every day and PRN as follows: Cleanse with wound cleanser or NS pat dry with gauze, apply collagen powder and mix with anasept, then add calcium with alginate, cover with border gauze, and may secure with tape as needed. Residents Affected - Some Resident #38 Record review of Resident #38's face sheet dated 03/27/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), diabetes (high blood sugar), bipolar disorder (mental illness that causes extreme mood swings), schizoaffective disorder (mental illness that affects how a person thinks, feels, and behaves) and altered mental status. Record review of Resident #38's comprehensive MDS assessment, dated 02/16/24 reflected a BIMS of 09 which indicated moderate impaired cognition. Resident #38 had pressure ulcer injury and care and was at risk for pressure ulcers. Record review of Resident #38's care plan dated 02/14/24 reflected a focus area which indicated Resident #31 had an unstageable pressure injury with interventions to administer treatments as ordered and to monitor for effectiveness. Record review of Resident #38's physician's orders dated 03/27/24 reflected an order dated 03/27/24 for wound care daily and PRN to left heel as follows: Cleanse with wound cleanser or NS, apply santyl and cover with border gauze, may secure with tape. An order dated 03/27/24 reflected wound care every day and PRN to the right MTP (big toe) as follows: cleanse with wound cleanser and pat dry, then apply Thera-honey, cover with border gauze. Resident #45 Record review Resident #45's face sheet dated 03/27/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included stroke, hemiplegia (paralysis) right side, altered mental status, and muscle weakness. Record review of Resident #45's comprehensive MDS assessment, dated 08/25/23 reflected BIMS 00 which indicated severely impaired cognition. Resident #45 was dependent of staff for toileting hygiene, and personal hygiene. Record review of Resident #45's care plan dated 01/29/24 reflected a focus area which indicated Resident #45 had an ADL self-care performance deficit r/t disease processes with interventions Resident #45 was totally dependent on staff for personal hygiene and toilet use. 2. During an observation on 03/26/24 at 02:46 PM, revealed incontinent care was provided to Resident #45 by CNA C. Observed CNA C make multiple wipes using the same disposable washcloth on the resident's upper abdomen. CNA C changed her gloves and put on new gloves and no handwashing or hand sanitizer use was observed. CNA C rolled the dirty brief under the resident. CNA C removed her gloves and put on new gloves and no handwashing or hand sanitizer use was observed. The aide cleaned the buttocks area with multiple back and forth swipes using the same disposable wipe. CNA C changed her gloves 455936 Page 18 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and used hand sanitizer and put on new gloves. CNA C placed a new brief under the old rolled up brief and assisted the resident to their back, removed the old brief and place the cleaned brief on the resident and repositioned the resident. During an interview on 03/26/24 at 04:00 PM with CNA C, she stated she did make several back-and-forth wipes with one disposable cleaning cloth when wiping the resident's lower abdomen. She stated she should have folded the wipe after each wipe or got a new wipe. She stated she did forget to use hand sanitizer between glove changes. She stated there was no reason not to wash her hands or use hand sanitizer except she forgot because she was nervous. She stated she had been trained on incontinent care. She stated the potential negative outcome could be cross contamination. 3. During an observation on 03/26/24 at 03:00 PM, revealed incontinent care was provided to Resident #1 by CNA D. While cleaning the coccyx area observed CNA D make multiple wipes using the same disposable wipe. CNA D folded the disposable wipe and made multiple wipes on both sides of the coccyx. CNA D removed her gloves and put on new gloves and no hand washing, or hand sanitizer use observed. CNA D rolled the old brief under the resident and placed the new brief under the dirty brief. CNA D removed her gloves and put new gloves on and no hand washing, or hand sanitizer use observed. CNA D placed clean the brief on the resident and covered the resident with a blanket. During an interview on 03/26/24 at 03:54 PM with CNA D, she stated when cleaning a resident, they should wipe once and fold the wipe and wipe again. She stated she made multiple wipes on the buttocks with the same wipe. She stated she thought she had folded the wipe each time. She stated her hands should be washed or use hand sanitizer between glove changes. She stated she did forget to use hand sanitizer between glove changes. She stated there was no reason she should have not used hand sanitizer between glove changes. She stated placing the clean brief under the rolled brief could cause cross contamination. She stated I just got caught up in the moment of doing incontinent care and forgot. You made me nervous. She stated she had received training on incontinent care. She stated the potential negative outcome could be cross contamination, infection or catching something. 4. During an observation on 03/27/24 at 09:30 AM, revealed wound care was provided to Resident #31, observed LVN A gather wound care supplies and place them in a clean tray. LVN A carried the tray into Resident #31's room and placed it on the bed side table. LVN A took gauze and tape out of tray on bed side table and placed on the resident's mattress. LVN A picked up the gauze and placed it over the wound. LVN A picked up the tape and secured the gauze to Resident #31's foot. During an observation on 03/27/24 at 10:00 AM, revealed wound care was provided to Resident #38. Observed LVN A gather wound care supplies and placed them in a clean tray. LVN A carried the tray into Resident #38's room and placed it on the bed side table. LVN A took cup of dry gauze, cup with santyl, and gauze and placed on bed side table. LVN A took cup of gauze and removed the gauze and dried Resident #38's wound bed. LVN A placed the cup back on the bed side table. LVN A picked up a cup of Santyl and using a wooden medicine spoon placed santyl in the wound bed. LVN A placed the cup of Santyl back on bed side table. LVN A picked up gauze and placed it on wound bed. During an interview on 03/27/24 at 11:10 AM with LVN A, she stated she should have cleaned the mattress and bed side table before placing supplies on it. She stated, I just did not think about cleaning the mattress or bedside table. She stated she had been trained on wound care and the proper steps. She stated the potential negative outcome could be bacteria getting on supplies and cross contamination. 455936 Page 19 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/27/24 at 03:00 PM with the DON, she stated the CNAs should follow policy when doing incontinent care. She stated the CNAs should use a new wipe with each wipe. She stated hands should be washed or ABHR used between glove changes. She stated all staff had been trained on handwashing and CNAs had been trained on incontinent care. She stated the potential negative outcome could be UTI if not wiping appropriately, injury to skin, infection, and skin breakdown. She stated wound care supplies should not be placed on unclean surfaces. She stated nurses had been trained on proper wound care. She stated the potential negative outcome could be spread of infection. During an interview on 03/28/24 at 09:00 AM with the ADM, she stated CNAs should not use one wipe for multiple wipes. She stated the ADON and DON were responsible for monitoring CNAs competency skills. She stated all staff had been trained on incontinent care. She stated the potential negative outcome could be infection. She stated hands should be washed or ABHR used between glove changes. She stated staff had been trained on handwashing. She stated the ADON and DON was responsible for monitoring staff for competency skills. She stated the potential negative outcome could be infection, transmitting infection to the resident from unclean hands as well as to themselves. She stated the nurse should have cleaned the surface before setting supplies on table or bed. She stated staff have been trained on wound care. She stated the ADON and DON was responsible for monitoring for compliance and competences. She stated the potential negative outcome could be risk of infection to the resident. Record review CNA C's competency evaluation for Peri/Incontinent Care dated 01-16-24 reflected CNA C met all competency skills for incontinent care. Record review of the hand hygiene competency check off audit form for CNA C dated 10/12/23 reflected CNA C passed the skills check off. Record review of CNA D's competency evaluation for Peri/Incontinent Care dated 01-16-24 reflected CNA D met all competency skills for incontinent care. Record review hand of the hygiene competency check off audit form for CNA D dated 09/13/23 reflected CNA D passed the skills check off. Record review of LVN A 'swound care competency dated 12-30-23 reflected LVN A passed skills competency. Record review of the facility's policy titled Perineal Care, dated 10/01/21, reflected the following: Policy: to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Steps in the Procedure 8d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe and/or obtain a clean wipe to clean the labia . 11. Remove gloves and discard into designated container. Wash and dry your hands thoroughly . Record review of the facility policy titled Hand Hygiene, dated 08/04/21, reflected the following: 455936 Page 20 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0880 Policy: Hand Hygiene is used to prevent the spread of pathogens in healthcare settings. Level of Harm - Minimal harm or potential for actual harm Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub (ABHR) to destroy harmful pathogens, such as Residents Affected - Some bacteria or viruses, on the hands. 1. You should always perform hand hygiene: . Before applying and after removing personal protective equipment (e.g., gloves, gown, mask, face shield/goggles) 2. You must perform hand hygiene (hand washing or the use of an ABHR) after contact with bodily fluids, such as urine . Record review of the facility's wound care competency, undated, reflected the following: Wound Care Competency . Gathers supplies (disinfectant for table/treatment cart, scissors, dressings, tape, wound cleanse or normal saline, PPE supplies, biohazard bag, and regular trash receptacle). Clean and disinfect work surfaces, allowing drying time to be complete, and establish a clean field . 455936 Page 21 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation , interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: Residents Affected - Many The facility failed to ensure the kitchen steamtable was maintained in safe operating condition. The facility failed to ensure that the kitchen oven was maintained in safe operating condition. The facility failed to ensure that the kitchen coffee machine was maintained in safe operating condition. These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies. The findings included: Observation on 03/26/24, at 09:25 AM, revealed the door to the coffee machine ajar and unable to close. Observation on 03/26/24, at 12:35 PM, revealed two pieces of folded cardboard in the left and the right doors of the oven. Observation on 03/26/24, at 12:36 PM, revealed the Food Service Manager retrieving the pureed food items from the oven and placing them on the right side of the steam table, not utilizing the middle of the steam table. During an interview on 03/28/24 at 09:08 AM, the Food Service Aide stated that the coffee machine had been out for two months. She said sometimes it worked and sometimes it doesn't. She said the oven doors had been broken for years. She said she could guess for at least three years. She said she had observed people trying to come and fix it, but it did not work. She said they have to place the pieces of cardboard on the doors, or the doors will open and fall on staff. She said if food was cooking, then the doors could open during the cooking process. She said they placed the cardboard so the ovens would heat up. She said the potential negative outcome was the doors falling on staff, or the cardboard could potentially burn, putting residents at risk if there were a fire. She said the cardboard had never fallen in the oven without the staff's knowledge. She said she did not know who was responsible for fixing broken equipment. During an interview on 03/28/24 at 09:27 AM, the Food Service Manager stated they had the cardboard in both oven doors to keep them from opening while using the oven and when they were not using the oven. She said they could potentially open and injure staff if they do not use the cardboard in the doors. She said the burn on her right forearm was from the oven. She said that if the doors were not correctly sealed, the food might not be cooking properly, but that they check the food by taking the temperature to ensure it was cooked. She said she had been employed with the facility for a year and a half, and the oven doors had always been that way. She said she had not noticed if they had to cook longer because of the broken oven doors. She said the entire facility was responsible for ensuring all broken equipment was fixed. She said everyone was aware that the oven doors were not working correctly. She said the ADM asked about the oven doors a couple of weeks ago. She said the overall potential negative outcome of the broken oven doors was employee injury and food safety. She said it 455936 Page 22 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was a gas stove but does not remember if there had ever been issues with gas leaks or other problems. She said the coffee machine had only been broken for about a week. She said the reason she said it had only been a week, and others would say a different time frame, was because the right side was leaking, and the left side was what broke a week ago. She said the potential negative outcome of the coffee machine not working properly was they may not mix the concentrate correctly, and the temperatures of the coffee might be off. She said that the DM had attempted to fix the coffee machine, but she was unsure what was wrong. She said she had been trained on what to do when there was broken equipment, and that was to let the DM know. She said the steam table had been broken since she started working at the facility. She said the Maintenance Supervisor looked at it once a couple of months ago. She said the potential negative outcome of the steam table not working correctly was the food temperatures could be off, but they do not place food on the portion that does not work. She said because the middle portion of the steam table did not work, they could not put all of their food on the steam table. She said she expected all kitchen equipment to work correctly. During an interview on 03/28/24 at 09:58 AM, the DM stated that the oven doors had been broken for at least 10 years. He said they had been using cardboard for the past 6 years to keep the door closed. He said that was implemented by a former employee who found that the cardboard worked. He said he had been trying to fix the oven for years and had last attempted in January 2024. He said the oven was so old that the parts for the oven doors were no longer being made. He said he had previously requested a new stove but was told that the budget needed more funding. He said the potential negative outcome of using the cardboard to keep the oven doors closed was employee safety and fire. He said although it was a gas stove, he had not smelled gas before. He said the oven door was not braced without cardboard and would not stay closed. He stated the door would fall. He stated that the temperatures between both ovens was different. He said the left side gets hot, but the right side was so so. When asked to describe so so,. He said the right side worked at about 85%. He said they know their food was fully cooked because they take temperatures. He said they have never had to delay meal serving times because of having to cook the food longer in the ovens. He said the system for monitoring was that if the equipment was broken, they replaced it, but certain items, if they cost more, were out of his ability to approve for replacement. He said he had been trained regarding broken equipment and maintenance repairs. He said they do not do preventative maintenance on their kitchen equipment. He said they monitor and address the issue if and when it breaks. He said the coffee machine had been out for the past 6 months. He said he was unsure of the date, but the last time a technician was at the facility for the coffee machine, he was told it was the compressor. He said the door of the machine had also broken. He said the potential negative outcome was that the concentrate might not be measured correctly. He said he drank the coffee, and it tasted good to him. He said he was aware that the coffee machine was broken. He said he expected all broken equipment to be fixed. He said the middle portion of the steam table had been broken for about 5 years. He said the potential negative outcome was they could not place all items on the steam table, which could affect food temperatures. He said they do check all food temperatures before serving. He said he was aware that the middle portion of the steam table was not working and believed it was a heating element out. He said he was responsible for ensuring all equipment was fixed and functioning at its total capacity. He stated he never reported the steam table or the coffee machine to anyone, including the ADM. During an interview on 03/28/24 at 10:41 AM, the ADM stated that she was aware that the doors on the oven were not working correctly. She said the DM and the Plant of Operations said the oven was so old that the parts needed for the oven were no longer being made. She said she was unsure who suggested the cardboard as a 455936 Page 23 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many solution. She said they discussed a new oven at one point, but there was never a definitive date. She said using the cardboard in the oven doors could be a fire hazard. She said she was unaware of anyone ever getting hurt. She said she was unaware that the coffee machine and the middle portion of the steam table were not working. She said they used the concentrate to make coffee but thought that was the process. She said she had no potential negative outcome from the faulty coffee machine. She said she didn't know if there was an actual measurement for concentrate for the coffee. She said that the potential negative outcome for the steam table would be that the food might not be at the proper temperature. She said the system for monitoring broken equipment was that if the Maintenance Supervisor could not fix it, they would contract out and then replace it if it could not be fixed. She said she had been trained to ensure that all equipment was working correctly and was ultimately responsible for ensuring that all equipment was not broken and working correctly. She said she does monthly kitchen walk-throughs and had not observed any broken equipment. She said she did not have any documentation to reflect her monthly observations of the kitchen. During an interview on 03/28/24 at 11:02 AM, the Maintenance Supervisor stated he knew that the oven doors, coffee machine, and steam table were not working at their total capacity. He stated the DM ordered parts for the oven, but they did not work. He stated he believed the facility needed a new oven, but it was not up to him. He stated that on the steam table, there was a section that was not working. He stated he was told about 5 months ago by the Food Service Manager that the steam table needed to be fixed. He stated that the oven doors had been broken for a while, at least over a year. He said that no one had told him about the coffee machine and that he believed the repairs for the coffee machine were contracted out. He said he did not know why the coffee machine had not been fixed. He said he did not do any preventative maintenance on any kitchen equipment. He said regarding training, he googled things and asked for help. He said he was not licensed and was considered more of a handyman. He said the potential negative outcome for broken equipment was that the oven could burn the staff, but he does not think there had been an issue. He said he did not know a potential negative outcome for the broken coffee machine. He said he could not get the coffee machine to work. He said he had no specific training for being the maintenance supervisor and the identified broken equipment. He said he learned independently and paid attention to others who tried to help him. He said he had not received formal training. He said he did not have a policy on fixing equipment. Record review of the U.S. Food and Drug Administration Food Code revealed: 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Record review of an email provided by the DM, dated 01/17/23 at 2:05 PM revealed that the DM sent an email to the Head of Plant Operations stating that they needed parts for the oven. (The specific part was not indicated.) Record review of an email provided by the DM, dated 03/9/23, revealed that the coffee vendor had scheduled the facility to be seen 03/14/23-03/17/23. (No specifics to fix the machine was indicated.) Record review of facility policy, Equipment Safety (dated April 2022) revealed: Policy 455936 Page 24 of 25 455936 03/28/2024 Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331

F 0908 All equipment is handled and operated in a safe manner to prevent accident or injury. Level of Harm - Minimal harm or potential for actual harm Procedure All food service equipment is regularly inspected and kept in good repair. Residents Affected - Many 455936 Page 25 of 25