Health inspection·May 4, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 3 residents (Resident #7) reviewed for tube feeding. 1. LVN H failed to check for residual (the amount of fluid/contents that are in the stomach) for Resident #7 prior to initiating a bolus feeding (feeding method using a syringe to deliver formula through feeding tube) and failed to follow physician orders. 2. LVN H failed to ensure Resident #7's head was elevated at a minimum of 30-degree angle while receiving bolus feeding. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations. Findings included: Record review of Resident #7's Face Sheet, dated 05/04/23, revealed Resident #7 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of encounter for fitting and adjustment of other gastrointestinal appliance and device (surgical opening into the stomach), unspecified protein-calorie malnutrition, gastro-esophageal reflux disease without esophagitis (stomach acid), and essential hypertension (high blood pressure). Record review of Resident #7's MDS Quarterly Assessment, dated 04/13/23, revealed Resident #7's had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. Resident #7's MDS Assessment Section K revealed nutritional approach was feeding tube. Record review of Resident #7's Care Plan, revised on 11/30/22, reflected the following: The resident requires tube feeding r/t swallowing problem. Goal: The resident will remain free of side effects or complications related to tube feeding through review date. Interventions: The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feeding. Monitor/document/report PRN any s/sx of: Aspiration - fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Record review of Resident #7's physician order dated 09/09/22 revealed an order for: Elevate HOB at least 30 degrees. Page 1 of 17 675032 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #7's physician order dated 09/09/22 revealed an order for: If gastric residuals are >50ml and presence of abdominal distention, nausea and/or vomiting, hold feeding and recheck in 1 hour, if gastric residual remains elevated after 2 hours notify physician for further orders. Record review of Resident #7's physician order dated 09/09/22 revealed an order for: Flush tube with 30 cc before and after feeding Record review of Resident #7's physician order dated 11/28/22 revealed an order for: Bolus 75ML of water via peg tube before and after bolus feeding. Record review of Resident #7's physician order dated 11/28/22 revealed an order for: six times a day Isosource 1.5 carton bolus 1 carton. Observation on 05/03/23 at 11:49 AM revealed LVN H preparing to provide Resident #7 his bolus feeding. The resident's bed was horizontal against the wall, and Resident #7 sat at the edge of the bed and leaned back vertical with his head leaning against the wall. The resident's chin was touching his chest. LVN H checked Resident #7's g-tube placement and flushed the g-tube with 30 cc of water. LVN H did not check for residual. LVN H provided Resident #7 one carton of Isosource 1.5 via gravity, and then flushed with 30 cc of water. Interview on 05/03/23 at 12:08 PM with LVN H revealed he had been employed for three days. He stated he was the nurse for Resident #7. LVN H stated the procedure before providing a resident with a bolus feeding, was to check for placement and residual and the resident's head had to be elevated at 30-45 degrees. LVN H stated he always checked for residual; however, he forgot to do it this time. LVN H stated based on his observation Resident #7 was sitting and was leaned back with his head against the wall. LVN H stated that was fine. LVN H stated he reviewed Resident #7's MAR prior to entering his room. LVN H and the surveyor reviewed Resident #7's physician orders, which reflected Resident #7 had an order for 75 ml of water to be administered before and after a bolus feeding. LVN H stated Resident #7 did have an order; however, it did not show on Resident #7's MAR. He stated if the order did not show on Resident #7's MAR he would not provide that to the resident. LVN H stated the risk for not checking for residual was that it could cause aspiration, and the risk for not following physician orders was that it could cause dehydration. During this interview, ADON E was next to LVN H, and she stated she checked Resident #7's orders. ADON E stated the order for 75 ml of water should be discontinued. Interview on 05/04/23 at 11:48 AM with the Dietitian revealed she had been seeing Resident #7 since November 2022 when she acquired this facility. The Dietitian stated Resident #7 had two orders: one being 75 ml of water before and after bolus feeding and another order for 30 ml before and after bolus feeding. She stated on 03/13/23 another Dietitian was overseeing her patients due to her being off and after reviewing Resident #7's clinical records it was determined that Resident #7 was only receiving the 30 ml of water before and after his bolus feedings. She stated Resident #7 had not been receiving his 75 ml of water before and after bolus feeding. The Dietitian stated the last time she met with Resident #7 was on 04/17/23, and she discontinued the orders of 75 ml of water and kept the order for 30 ml of water before and after his feedings because 30 ml of water had been meeting Resident #7's needs. The Dietitian stated Resident #7 did have an active order for 75 ml of water; however, it should had been discontinued and removed from Resident #7's order summary. Interview on 05/04/23 at 1:51 PM with the DON revealed her expectations were for her nurses to 675032 Page 2 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few follow physician orders and the orders on the MAR. The DON stated prior to providing a resident with a bolus feeding her nurses should assess the patient by checking for placement and residual. She stated if the resident was in bed, depending on the order, the resident's head should be at least 30 degrees elevated to prevent aspiration. The DON stated LVN H spoke with her yesterday regarding Resident #7's orders, and it was determined the order for 75 ml of water before and after bolus feeding should had been discontinued. The DON stated she contacted the Dietitian yesterday (05/03/23) and asked the Dietitian to visit today (05/04/23) so that she could review Resident #7's orders and have her talk to the surveyor regarding Resident #7's clinical records. The DON stated she did not want to discontinue Resident #7's orders just yet because she did not want the surveyor to think bad about the orders. The DON stated the order for 75 ml of water was placed as standing orders, and they failed to discontinue the order. The DON stated there was no risk to the resident because Resident #7 was not dehydrated. Record review of the facility's current Enteral Tube Feeding via Syringe (Bolus) policy, revised date March 2015, reflected the following: .Preparation: 1. Verify that there is a physician order for the procedure. Steps in the Procedure .4. Elevate head of bed 30* - 45* (semi-Fowler's position) 7. Verify placement of tube 10. Check gastric residual volume. 11. If acceptable GRV has been verified, flush tubing with at least 30 mL warm water (or prescribed amount). Initiate Feeding: 1. Attach sixty (60) mL syringe (with transition adapter if necessary) to the tube and unclamp the tube. 2. Fill the syringe with prescribed amount of enteral feeding to be given. Unclamp the tube and allow feeding to flow by gravity .4. Unless otherwise ordered, follow the feeding with 30-60 mL of warm water 675032 Page 3 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 7 of 35 days (01/21/23, 01/22/23, 01/29/23, 02/12/23, 02/19/23, 02/26/23, and 03/18/23) reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 7 days (Saturdays and Sundays) beginning 01/01/23 until 04/30/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. Findings included: Record review of timecards for RN F, and RN G for the time-period of 01/01/23 to 04/30/23 revealed there was not eight consecutive hours of RN coverage for 7 out of 35 days (01/21/23, 01/22/23, 01/29/23, 02/12/23, 02/19/23, 02/26/23, 03/18/23) reviewed for weekend RN coverage on Saturdays and Sundays. Record review of the Employee Timesheets for the time-period of 01/01/23 to 04/30/23 revealed the following for RN F: - Saturday 01/21/23, RN F timesheet: Time in 9:46 PM (Saturday) - Out 6:13 AM (Sunday); 2.23 hours worked on Saturday 01/21/23. - Sunday 01/22/23, RN F timesheet: Time in 9:34 PM (Sunday) - Out 6:30 AM (Monday); 2.43 hours worked on Sunday 01/22/23. - No RN coverage for Sunday (01/29/23). - Sunday 02/12/23, RN F timesheet: Time in 9:42 PM (Sunday) - Out 6:38 AM (Monday); 2.30 hours worked on Sunday 02/12/23. - Sunday 02/19/23, RN F timesheet: Time in 9:49 PM (Sunday)- Out 6:31 AM (Monday); 2.18 hours worked on Sunday 02/19/23. - Sunday 02/26/23, RN F timesheet: Time in 9:36 PM (Sunday)- Out 6:34 AM (Monday); 2.40 hours worked on Sunday 02/26/23. Record review of the Employee Timesheets for the time-period of 01/01/23 to 03/31/23 revealed the following for RN G: - No RN coverage for Sunday (01/29/23). - Saturday 03/18/23, RN G timesheet: Time in 9:51 PM (Saturday)- Out 7:24 AM (Sunday); 2.15 hours worked on Saturday 03/18/23. Interview on 05/04/23 at 10:23 AM with the Staffing Coordinator revealed she has been working at 675032 Page 4 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility since December 2022. She stated she was responsible for completing the nursing schedules. She stated she was only aware of the 8 consecutive hours. She stated the Administrator and the DON reviewed the nursing schedules. She stated she was aware of the 8 hours but not aware RN coverage needed to be eight consecutive hours a day. She stated she thought the weekends were being covered by the RNs. She stated it was important to have an RN in the facility because they oversaw the LVNs and could provide resource skills and clinical guidance to other staff. Interview on 05/04/23 at 1:34 PM with the DON revealed the Staffing Coordinator was responsible for completing the nursing schedule. She stated she was responsible for overseeing the schedules and if she was not working the Administrator was responsible. The DON stated she just started working at the facility on 04/18/23; however, she was not aware RN coverage needed to be eight consecutive hours a day. She stated she came from a different facility, and they would do things differently. Interview on 05/04/23 at 2:06 PM with the Administrator revealed the Staffing Coordinator was responsible for completing nursing schedules, and the DON was responsible for overseeing the schedules. She stated the DON started working on 04/18/23; however, before her she had another DON. She stated she reviewed her nurses' timecards before providing them to the surveyor, and she did not observe any discrepancies regarding weekend RN Coverage. The Administrator and the surveyor reviewed the RN timecards from 01/01/23 through 04/30/23. The Administrator stated she was not aware the RN coverage needed to be 8 consecutive hours a day. A policy was requested; however, the Administrator stated they did not have one. 675032 Page 5 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 5 (Resident# 40, Resident#43, Resident #72, Resident #139, and Resident #47) of 18 residents observed for medication administration and storage. The facility failed to ensure insulin pen was labeled with opening date. The facility failed to ensure a bottle of multivitamin gummies was not left unsupervised in Resident #40's room in security unit. The facility failed to ensure - clonazepam 2 tablets of Resident#43 and Resident #72 were both stored in one cup, -Eliquis 1 tablets of Resident # 139 were not left in MA A cart unlabeled, and -Resident #47 medication was popped at the right time and stored properly. This failure could place residents at risk of overmedication, misuse, adverse drug reactions, and not receiving the intended therapeutic effects. Findings included: 1.Review of Resident #40's Face sheet, dated [DATE], revealed the resident was a [AGE] year-old male with an original admission date to the facility on [DATE] and readmission on [DATE]. Resident #40's had a diagnosis that included unspecified schizoaffective disorder), bipolar type (mental health condition), iron deficiency and dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance. Review of Resident #40's MDS assessment, dated [DATE], reflected the resident was cognitively severely impaired.He need assistance with ADLS. Record review of Resident #40's physician order, dated [DATE], revealed she had an order for centrum 50+ multivitamin one time a day for supplement. Record Review of Resident #40's care plan dated [DATE] revealed Resident#40 was unable to self-administer medication rule out cognitive impairment. Interventions where medications will be administered by licensed or certified members. Observation and interview on [DATE] at 11:16 AM, revealed Resident #40 was in his room on his bed. Observation revealed a bottle of multivitamin gummies on Resident's #40 nightstand. Resident #40 stated he takes the medication daily. He stated his brother brought the bottle of multivitamin gummies and he had been keeping it in his room. He stated he administers to himself once a day. Interview and observation on [DATE] at 12:30 PM, RN B revealed she mainly works with Resident #40. 675032 Page 6 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She stated when a resident had a prescribed medication the nurses keep the medication in the nurse's cart. RN B and State Surveyor went into Resident #40's room and observed the bottle of multivitamin. RN B stated she was aware that she had a bottle of multivitamins in his room. RN B stated they were supposed to lock the medication in Resident #40 locker after they received an order from the nurse practitioner. She stated the risk of leaving the medication in the room was that it could cause the resident to miss use the medication, and the medication could fall into the wrong hands considering Resident #40 was in security unit. She stated she had done training on medication storage. Interview on [DATE] at 01:23 PM with the DON revealed the facility does not have residents who self-administer medications. She stated she was aware of Resident #40 having the bottle of calcium gummies in his room .She stated she had called the nurse practitioner who had given the order for resident to keep the gummies in the room and told her it was unacceptable, and she had told the nurse to exchange the gummies with fruit gummies .DON stated she did not know the nurses did not do as she had instructed them to remove the medication from Resident #40's room. The DON stated Resident #40 had no assessment done to self-administer medication. She stated her expectations was staffs lock the medications in the nurses' carts or at the resident locker. She stated the risk of leaving medications in Resident #40 room could be harmful to other residents in the locked unit. Interview on [DATE] at 01:34 PM with the MA A, revealed she was aware of Resident #40 having the bottle of calcium gummies in his room. MA A stated Resident #40 take the medication by himself she does not administer to him. She stated the staff were supposed to lock the medications in the carts or at the resident locker but resident #40 locker does not have a lock and key. She stated the risk of leaving medications in residents' room, other residents could take them. She stated she has done training on medication storage and resident safety. 2.Review of Resident #72's Face sheet, dated [DATE], revealed the resident was an [AGE] year-old female with an original admission date to the facility on [DATE]. Resident #72 had a diagnosis that included unspecified dementia, anxiety, and major depression. Review of Resident #72's MDS assessment, dated [DATE], reflected the resident had a BIMS score of 3 that revealed Resident #72 was cognitively severely impaired. Record review of Resident #72's physician order, dated [DATE], revealed she had an order for clonazepam 0.5mgs 1 tablet by mouth two times a day for agitation. 3.Review of Resident #43's Face sheet, dated [DATE], revealed the resident was a [AGE] year-old female with an original admission date to the facility on [DATE]. Resident #43 had a diagnosis that included schizophrenia, anxiety, and major depression. Review of Resident #43's MDS assessment, dated [DATE], reflected the resident had a BIMS score of 4 that revealed Resident #43 was cognitively severely impaired. Record review of Resident #43's physician order, dated [DATE], revealed she had an order for clonazepam 1 mgs 1 tablet by mouth two times a day for anxiety. 4.Review of Resident #139's Face sheet, dated [DATE], revealed the resident was an [AGE] year-old male with an original admission date to the facility on [DATE]. Resident #139 had a diagnosis that included schizophrenia, anxiety, and hypertension (high blood pressure). 675032 Page 7 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #139's MDS assessment, dated [DATE], reflected the resident had a BIMS score of 1 that revealed Resident #139 was cognitively severely impaired. Record review of Resident #139's physician order, dated [DATE], revealed he had an order for Eliquis 5 mgs 1 tablet by mouth two times a day for encephalopathy (a brain disease that alters brain function or structure). Observation on [DATE] at 08:11AM on MA A cart revealed there were 3 medication cups with medications that were not labeled. Interview on [DATE] at 08:13 AM with MA A revealed she had kept the medication with cups in her cart and were not labeled. She stated she was aware not to mix medication for two different residents in one cup. She also stated she was aware it was wrong to keep medications with cups not labeled in the cart. She stated she put different resident medications together in one cup because she was short of medication cups. She stated the facility have enough cups, but she could not explain why she did so. She mentioned the two medications in one cup were for Resident #43 and Resident #72. She revealed the other medication cup was for Resident #139. MA A revealed the risk of leaving medications with cups in her cart not labelled and mixing two residents' medication in one cup may lead to medication error. She stated she had done training on medication storage and administration. Interview on [DATE] at 09:46 AM with the DON revealed her expectation was her staffs to follow the five rights of administering medication. She stated when resident states they will not take the medication she expected MA A to have labeled and try again later. She stated MA A was not supposed to put two residents' medication in one cup, and the facility do not have shortage with medication cups. She stated storing medications on MA A cart without labelling was an opportunity of medication error. DON stated she is new in this facility, she has not done training with staffs on medication storage and administration, but she expects the staffs to have done some trainings since the facility was preparing for the survey. Observation on [DATE] at 02:29 PM of the nurse's medication cart used for the 200 Hall front with LVN C revealed, one insulin pen of Levemir which was opened partially used and was not labelled with opening date. Interview on [DATE] at 02:36 PM with LVN C revealed it was all nurses' responsibility to check the carts every shift for expired medication and labelling. LVN C stated it is the responsibility of the nurse that remove insulin from the fridge to label with an opening date. He stated he is aware all insulins need to have an opening date so that they can know when they expire. He stated failure to label with opening date may affect the potency of insulin after it has expired. He stated he has done training on insulin labeling and storage. Observation on [DATE] at 02:42 PM of the nurse's medication cart used for the 200 Hall back with LVN D revealed, I tablet of cefuroxime was missing when counting medication locked on the narcotic box. LVN D was observed removing the tablet from her pocket and put it on the medication plastic envelop. Interview on [DATE] at 02:52 PM with LVN D revealed she had pulled the medication from the bubble pack so that when it is time to administer, she will administer to Resident # 47. She stated she was aware she only needs to pop the medication when it is time to administer knows putting in the pocket will contaminate it was all nurses' responsibility to check the carts every shift for expired 675032 Page 8 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication and labelling. LVN C stated it is the responsibility of the nurse that remove insulin from the fridge to label with a opening date. He stated he is aware all insulins need to have an opening date so that they can know when they expire. He stated failure to label with opening date may affect the potency of insulin after it has expired. He stated he has done training on insulin labeling and storage. Interview on [DATE] at 3:22 PM with the DON revealed her expectation was for staff to pop the medication only when they were ready to administer the medications to residents. She stated she understood her staff were having problems with pharmacy services and since she was new, she had realized the staff needed more training on of pharmacy services. She also stated she expected the staff to label inulin pens with opening dates once they were removed from the refrigerator. She stated the ADONs were responsible of following up behind the nurses to ensure the insulins have opening dates. She stated it was the facility requirement for ADONs to audit the carts weekly or biweekly. She stated putting an opening date on insulin was a standard process for quality of care. She stated the importance of the opening date was so the staff would know when the insulin expired. Interview on [DATE] at 3:33 PM with the ADON revealed her expectation was for the staffs to follow the facility policy on medication administration and storage. She stated she expect the nurse when they open insulin, they put an opening date. She stated she do audit the carts weekly and the last time she checked was [DATE]. Record review of the facility's Administering Medication policy, revised date [DATE], reflected the following: .7. The individual administering medication must check the label verify the right resident, right medication, right dosage, right time, and right method(route) before administering medications. 9 .When opening a multi-dose container, the date opened shall be recorded on the container 24.Residents may self-administer their own medications only if the attending physician in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Record review of facility's Storage of Medication policy, revised date [DATE], reflected the following: .1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. 8.Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications will be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents 675032 Page 9 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0791 Provide or obtain dental services for each resident. 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 assist residents in obtaining routine and 24-hour emergency dental care for two (Residents #36 and #71) of 18 residents reviewed for dental services. Residents Affected - Some The facility failed to assist in providing routine dental services for Resident #36 and #71. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life. Findings included: Review of Resident #36's face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease, repeated falls, difficulty walking, hypertension (high blood pressure), protein calorie malnutrition, dysphagia, oropharyngeal phase (inability to initiate the act of swallowing). Review of Resident #36's MDS, dated [DATE], revealed a BIMS score of 11 indicating the resident had moderately impaired cognition. His Functional Status indicated he required supervision in all his ADLs. Resident #36 required supervision with oral hygiene. His Oral/Dental Status did not indicate broken or loose-fitting dentures or no pain with chewing. Review of Resident #36's Order Summary Report revealed Resident #36 had a regular diet, regular texture, regular consistency with start date of 02/22/23. Resident #36 had Dental Care PRN with a start date of 02/14/22. The Order Summary Report reflected to provide double meat portions with a start date of 03/23/22. Review of Resident #36's care plan was requested but not provided. Interview and observation on 05/02/23 at 11:48 AM, Resident #36 revealed he needed to see a dentist about getting dentures because it was sometimes hard to eat some of the food the facility served. He denied any pain when eating. He stated he had lost his teeth over time due to not seeing a dentist. Observation of his mouth revealed Resident #36 was without teeth in his upper and lower gums. Resident #36 stated he did not get assistance or daily reminders to complete oral hygiene. Resident #36 stated he had mentioned it before that he would like to have dentures, but he was unsure whom he told. Resident #36 stated no one had followed up with him about seeing a dentist for a check-up or to receive dentures. He stated having dentures would give him more options to eat better foods. Review of Resident #71's Face Sheet, dated 05/04/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer growth and division of abnormal cells), chronic viral hepatitis C (infection that causes liver inflammation), hypertension (high blood pressure), mild protein calorie malnutrition, chronic kidney disease, cognitive communication deficit, and unsteadiness on feet. Review of Resident #71's MDS, dated [DATE], revealed a BIMS score of 11, indicating the resident's cognition was moderately impaired. His Functional Status indicated he required assistance with all of his ADLs and set up with help from staff with eating and one person assist with personal hygiene. His Oral/Dental Status did not indicate broken or loose-fitting dentures or no pain with chewing. 675032 Page 10 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #71's Order Summary Report revealed Resident #71 had a regular diet, regular texture, regular consistency with a start date of 03/01/23. The Order Summary Report reflected Resident #71 had Dental Care PRN with a start date of 10/01/22. Review of Resident #71's progress note dated 04/13/23 at 4:08 PM, revealed during care plan meeting Resident #71 requested to see the dentist, wants dentures. Review of Resident #71's care plan, dated 10/14/22, revealed he had oral/dental health problems related to poor oral hygiene. Goal included resident will be free of infection, pain, or bleeding in the oral cavity. Intervention included administer medications as ordered. Coordinate arrangements for dental care, transportation as needed/as ordered. Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Interview and observation on 05/03/23 at 9:50 AM, Resident #71 revealed the care he received from staff was good; however, the services such as dental care was not good. Resident #71 stated the facility did not provide him with services outside of the facility. Resident #71 stated he had requested dentures a couple of times, and no one has followed up with him or provided the service. Observation of his mouth revealed Resident #71 was without teeth in his upper and lower gums. Resident #71 stated he did not get assistance or daily reminders to complete oral hygiene. Resident #71 stated he spoke with the previous Social Worker concerning dental services. Interview on 05/04/23 at 3:10 PM, the Social Worker revealed she was new to the facility and the facility was phasing out from one dental agency to another that would start soon. The Social Worker stated the new dental company had reached out to the facility to enter the building so it would be very soon. The Social Worker stated she did not see anything about dental in Resident #36's file or progress notes. The Social Worker stated when looking in the previous Social Worker's binder, Resident #36 was on the list to be seen but was not seen. The Social Worker stated Resident #36 had documents showing a request for the resident's representative signature which was signed and returned, but no services had been provided. During the interview, the Social Worker contacted the current provider who stated Resident #36's doctor signature was needed for services. The current provider informed the Social Worker the request had been made the middle of March 2023, and the resident had never been seen, and there were no notes indicating where they were getting doctor's signature. The Social Worker stated she did not see anything about dental in Resident #71's file or progress notes. The Social Worker stated she did not see Resident #71 on the list to be seen by the dentist or for dentures. The Social Worker stated the last dental visit for him was in May 2022. The Social Worker stated dental services were provided to residents at least quarterly. The Social Worker stated the dental services provided by the current dental services were at the facility on a monthly basis. The Social Worker stated she could not give any details why all residents were not seen at some point or on a regular basis. The Social Worker stated it was important to have regular dental check-ups for proper oral hygiene, and that residents had a right to request dentures to promote self-dignity. Review of facility policy titled Dental Services revised December 2016 reflected the following: .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 1. Routine and 24-hour emergency dental services are provided to our residents through: 675032 Page 11 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0791 A. Level of Harm - Minimal harm or potential for actual harm A contract agreement with a licensed dentist that comes to the facility monthly. B. Residents Affected - Some Referral to the resident's personal dentist. C. Referral to community dentists; or D. Referral to other health care organizations that provide dental services. .Social services representatives will assist residents with appointments, transportation arrangements, . 675032 Page 12 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for 10 of 10 pureed diets reviewed for nutritive value. Residents Affected - Some The facility failed to ensure [NAME] L following the menu when preparing the pureed lunch meal. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Observation of [NAME] L preparing pureed lunches on 05/02/23 at 11:09 AM, revealed [NAME] L put steaming water, Salisbury steak, milk, and thickener into a blender. She then blended the mixture. The pureed meat appeared to have a pudding consistency. [NAME] L then moved to mixing mashed potatoes, mixing instant mashed potato flakes with steaming water, milk, and butter. During interview on 05/02/23 at 11:11 AM, [NAME] L revealed she was the cook on the morning shift and was responsible for preparing resident meals. [NAME] L stated she did not have a recipe for the Salisbury Steak puree. [NAME] L stated she had worked in the kitchen for 17 years, that most menu items were add water based and water was mostly used to create food items such as the mashed potatoes and purees. [NAME] L stated she will fortify the items with milk and butter. [NAME] L was asked if she would ever consider using broth or the juice from cooking the Salisbury Steak, she replied, Residents will be having gravy for the added flavor. [NAME] L stated she did not see any risk to the resident by using water to prepare meals. During interview on 05/02/23 at 11:11 AM, the Dietary Manager M revealed kitchen staff should follow the recipe when preparing pureed food. The Dietary Manager M stated when staff prepared pureed foods the [NAME] should use broth from the food. He stated using water could change the flavor and would take away the nutritive value. The Dietary Manager M stated there was a recipe that the [NAME] should have followed for all meal items, and he expected for the Cooks to refer to the recipe when they have questions. During interview on 05/03/23 at 10:26 AM, the Registered Dietitian revealed all menu items have a recipe that should be followed. The Registered Dietitian stated no water should be added to a menu item, this could be a risk to all residents. The Registered Dietitian stated broth was the suggested alternative liquid to be used even when preparing fortified foods. The Registered Dietitian stated she expected for Cooks to follow all recipes for preparing meals. Record review of the facility's recipe dated 04/12/23 for pureed meals reflected: Measure number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency. Place food in blender or food processor. Add liquid, if needed (ex. Reserved liquid, broth, juice, milk, gravy or sauce), to assist with pureeing. Puree with the blender or food processor until smooth. NOTE: Water should not be used as a liquid to puree foods. 675032 Page 13 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0804 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy revised November 2015 titled Therapeutic Diets reflected: .Routine menus are planned by the Food Services Manager, and approved by a Registered Dietitian for nutritional adequacy Residents Affected - Some 675032 Page 14 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest in two of two rooms (room [ROOM NUMBER] and #217) on Hall 200. Residents Affected - Few The facility failed to ensure room [ROOM NUMBER] was free of roaches. The facility failed to ensure room [ROOM NUMBER] was free of ants. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: 1. Review of Resident #42's Face Sheet, dated 05/04/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder, Bipolar Type, Malignant Neoplasm of Prostate (cancer of the groin area), cognitive communication deficit, alcohol abuse (unhealthy alcohol drinking), nicotine dependence (habitual smoker), Hypertension (high blood pressure), protein calorie malnutrition (not eating enough calories). Review of Resident #42's MDS, dated [DATE], revealed a BIMS score of 03 indicating his cognition was severely impaired. His Functional Status indicated he required supervision in all his ADLs. Resident #42 required supervision with one person assist with personal hygiene. Review of Resident #42's care plan revised on 10/14/22, revealed Resident #42's does not address his ability or inability to have or keep a safe or clean personal environment. 2. Review of Resident #73's Face Sheet, dated 05/04/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included disorders or nose and sinuses, alcohol abuse (unhealthy alcohol drinking), hypertension (high blood pressure), protein calorie malnutrition (not eating enough calories). Review of Resident #73's MDS, dated [DATE], revealed a BIMS score of 11 indicating his cognition's was moderately impaired. His Functional Status indicated he required supervision in all his ADLs. Resident #73 required supervision with one person assist with personal hygiene. Review of Resident #73's care plan revised on 01/26/22 revealed the care plan did not address his ability or inability to have or keep a safe or clean personal environment. 3. Review of Resident #47's Face Sheet, dated 05/04/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Dementia, lack of coordination, Hypertension (high blood pressure), Major Depressive Disorder, Anxiety, muscle wasting, protein calorie malnutrition (not eating enough calories). Review of Resident #47's MDS, dated [DATE], revealed a BIMS score of blank. Her Functional Status indicated she required total dependance in all his ADLs. Review of Resident #47's care plan revised on 03/17/23 revealed Resident #47 required tube feeding. 675032 Page 15 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The care plan reflecte: Goal: I will maintain adequate nutrition, hydration status, and stable weight. Intervention: Assist me with administration of tube feeding and water flushes per doctor orders. Observation and interview on 05/02/23 at 2:33 PM with Resident #42, revealed the resident's room had an odor and roaches were observed crawling up the wall into the corner over his bed. Resident #42 was standing in front of his bed and expressed that he did not know how long the roaches had been in his room. Resident #42 stated he saw the roaches crawling in his personal belongings, in drawers, and around the room. Resident #42 stated the facility was aware there were roaches in his room. Resident #42 stated he did see housekeeping come in and clean; however, he had not seen anyone come in and spray for bugs. Resident #42 stated he was going to move to a new room but was not sure when. Observation on 05/03/23 at 10:11 AM, of Resident #47's room revealed ants crawling along the baseboard beside the bed, behind the IV pole. Observation also revealed a sticky substance on the floor near the baseboard underneath the pole. Resident #47 was observed sitting in her wheelchair watching television. Resident #47 was nonverbal and could not respond to interview. Observation and interview on 05/03/23 at 10:14 AM with Resident #73 standing in his room next to his bed. Resident #73 stated he was responsible for moving his personal items from one room to the other. Observation of 15-20 roaches crawling over the walls heading towards Resident #42's side of the room to the top of the ceiling. Resident #73 stated it was decided a couple of days ago that we would be moving to another room due to the roaches, but they were just now moving today. Resident #73 stated he was not sure why the move did not take place until now. Resident #73 stated he was glad to be moving because he did not like that all these roaches were around. Resident #73 stated there was an infestation of roaches. Resident #73 stated the facility was notified about the roaches, but he did not know they were not supposed to be here and that they were in the room for a while before anyone did anything about it. Resident #73 stated he saw housekeeping come in just to take out the trash, but no one did anything about the roaches. During interview on 05/03/23 at 3:00 PM with CNA I revealed Resident #42 liked to snack and keep food in the drawers in the room and did not let staff clean. CNA I said, I enter the room. I attempt to take out the trash and pick up where I can. He stated Resident #42 liked to keep soda in his room which led to the roaches and ants that were in the rooms. CNA I stated, When I saw the roaches and ants, I notified the nurse, not sure who the nurse was because I was new to the facility. CNA I stated he had seen ants in Resident # 47's room, probably due to her being on tube feeding diet. CNA I stated, I feel like all the staff knew about the rooms having sugar ants and roaches. It has been a few days since I told the nurse about the pest. During interview on 05/03/23 at 3:39 PM with Housekeeping Aide J revealed Resident #42's room had roaches and ants. He stated he observed them in the rooms at least three days ago, last Sunday. Housekeeping Aide J stated he notified his manager, together they had gone into Resident #42 and #73's room together and seen the pest all over the room. Housekeeping Aide J stated he expected his supervisor to follow-up with a resolution to get rid of the pest. Housekeeping Aide J stated he had not returned to the room for any cleaning or disinfection. During interview on 05/03/23 at 4:00 PM, with LVN D revealed Resident #42 would refuse showers. LVN D stated yesterday was the first day she learned of the pest in the rooms on the 200 Hall. LVN D stated he had not received any complaints from residents of the pest or had not received any concerns of residents with skin conditions. LVN D stated having pest in the facility could cause harm to residents by creating illness. 675032 Page 16 of 17 675032 05/04/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During interview on 05/03/23 at 4:35 PM with Pest Control Technician revealed he acquired the building on 04/20/23, which he came in and attended to rooms on the 200 hall and 100 Hall. He stated today he was called to enter the facility to treat room [ROOM NUMBER] and would return in two weeks for a follow-up. The Pest Control Technician treated only room [ROOM NUMBER] today. According to Pest Control Technician, having pest in the facility could lead to an unclean environment. The Pest Control Technician stated when he was alerted to the problem it was his responsibility to come and treat the facility. During interview on 05/03/23 at 4:36 PM, with the Housekeeping Manager K revealed about a week ago he went into Rooms #216 and #217 and saw roaches. Housekeeping Manager K stated Resident #42 hoards a lot of food in the refrigerator and drawers. The Housekeeping Manager K stated he notified the Administrator in the stand-up meeting of the ants and roaches on the hall. The Housekeeping Manager K stated once he notifies the Administrator it was her responsibility to reach out for pest control service. According to the Housekeeping Manager K he had not seen or heard anything about ants. During interview on 05/03/23 at 4:47 PM, with The Administrator revealed in April the facility transitioned to a new pest control service. According to the Administrator she was alerted to the room on yesterday. The Administrator stated she saw issues with roaches in Rooms #216 and #217 and called for services to have the room treated. The Administrator stated at that time she relocated residents to a new room. During interview on 05/04/23 at 5:09 PM, with the Administrator stated she thought about the conversation on yesterday when asked about pest control. The Administrator stated on 04/20/23 new pest control services came out to the facility to treat the kitchen, hall 100 and specific rooms (217 & 223) on 200 hall that had prior issues. The Administrator further revealed that due to Surveyor finding medications in other resident rooms she told staff to do a sweep of the building. The Administrator stated the only reason she saw the roaches in the room was due to the sweep of the building looking for medications and this is when she saw the roaches. The Administrator stated no one had notified her about the room prior to the sweep of the building being done. The Administrator stated on 04/20/23 there were no roaches identified in Resident#42 and 73's room when pest control came for treatment, she stated she had ants in room [ROOM NUMBER] with no issues on 200 Hall. The Administrator stated she was not aware of a current ant problem. The Administrator stated she currently did not have a Maintenance Director therefore she had stepped into the role of contacting pest control. The Administrator stated she walked the halls of the facility, and she was able to identify the pest control needs of the facility and take action. The Administrator stated due to the population in the facility, this led to having pest in the building. The Administrator stated she was actively doing something about the pest in the building. Record review of the previous pest control visits revealed a date of March 2022. Review of facility policy titled Pest Control revised May 2008 reflected: .Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 675032 Page 17 of 17