Health inspection·July 11, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 20 (Resident #15) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #15's dignity while dining when staff did not serve the resident their lunch tray at the same time as other residents at the same table for lunch on 07/09/2024. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #15's Face Sheet dated 07/09/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included dementia (memory, thinking difficulty), abnormality of albumin (problems with liver and kidney function), epiphora due to insufficient drainage (excessive watering of the eye), stenosis of right lacrimal punctum (narrowing of the external opening of the eye), stenosis of left lacrimal punctum (narrowing of the external opening of the eye), age related nuclear cataract (hardening of the center part of the eye), hypertensive retinopathy (damage to blood vessels in the eye due to high blood pressure), vitamin D deficiency, muscle wasting, lack of coordination, cerebral infraction (long term effects of a stroke), hypokalemia (low potassium levels), abdominal pain, repeated falls, need for assistance with personal care, unsteadiness on feet, iron deficiency, hyperlipidemia (high cholesterol), Alzheimer's disease (brain disorder that gets worse over time), mood disorder, nutritional anemia (not enough healthy red blood cells), type 2 diabetes mellitus with unspecified complications (high blood sugar), hypo-osmolality and hyponatremia (low plasma sodium), depression, hypertension (high blood pressure), muscle weakness, age related osteoporosis (skeletal disorder), dysphagia (difficulty swallowing), difficulty walking, cognitive communication deficit (problems with communication), and symbolic dysfunctions (development disorder of speech and language). Record review of Resident #15's Quarterly MDS dated [DATE] revealed that Resident #15's BIMs score was 8 which meant the resident was moderately impaired . Resident #15's comprehensive care plan dated 11/04/2023 revealed resident had impaired communication due to impaired cognition and hearing difficulty. Page 1 of 13 675053 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #35's Face Sheet dated 07/09/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included anxiety, anterior subcapsular polar (cloudiness in the eye), nuclear cataract (hardening of the center part of the eye), long term use of anticoagulants (blood clot medication), osteoarthritis (joint disease), post COVID, history of falling, difficulty walking, lack of coordination, weakness, pain in the spine, abnormal posture, need for assistance with personal care, unsteadiness on feet, abnormalities of gait and mobility, atrial fibrillation (abnormal heart rhythm), muscle wasting, hypo-osmolality and hyponatremia (low plasma sodium), basal cell carcinoma of skin (skin cancer), cognitive communication deficit (problems with communication), muscle weakness, and chronic embolism and thrombosis of unspecified vein (blood clots in blood vessels). Record review of Resident #35's Quarterly MDS stated 02/08/2024 revealed she had a BIMs score of 99, which meant Resident #35 was unable to complete the assessment for mental status. Observation of dining services on 07/09/2024 at 12:00pm revealed that resident #35 received her meal tray at 12:08pm while her table mate Resident #15 did not get her tray until 12:23pm. Observation further revealed that after Resident #35 got her meal tray staff passed trays to the all the other residents in the dining room before realizing Resident #15 did not have her meal tray. An interview with Resident #15 on 07/09/2024 at 12:31pm revealed the resident did not want to talk to the state surveyor. An interview with CNA C on 07/11/2024 at 8:23am revealed the policy for dining tray pass was that all residents at the same table were to receive their meal trays before staff move on to the next table. CNA C stated that the nurses were responsible for ensuring all residents at the same table have their trays before passing trays to another table. She stated the negative outcome of a resident not getting his or her tray at the same time could result in the resident could become upset about not getting his or her food. She stated she did not know why Resident #15 did not get her tray before staff moved onto the next table. An interview with CNA B on 07/11/2024 at 8:30am revealed the policy for dining tray pass was that all residents get their trays before moving on to the next table. CNA B stated that the nurses and aids were responsible for ensuring all residents at the same table had their trays before passing trays to another table. She stated that sometimes the kitchen gets busy, and the kitchen does not have their food as reason they may have to wait for their food. She stated the outcome of a resident not getting their food at the same time could be that the resident felt left out. An interview with the DON on 07/11/2024 at 8:40am revealed the policy for dining tray pass was that all the trays for a table should come out together. She stated the nurse and everyone in the dining room was responsible for ensuring all residents at a table had their meal tray before moving to the next table. She stated by a resident not getting his or her meal tray at the same time as their table mate could result in emotional issues or the resident feeling left out. She stated she does not know why Resident #15 did not get her meal tray at the same time as her table mate. She stated staff must pay better attention. An interview with the ADM on 07/11/2024 at 8:48pm revealed to the policy for .dining tray pass was to make sure everyone gets fed at the same time before moving on. She stated that all staff were responsible for ensuring all residents had their meal tray at the table before moving on. She stated by not giving residents their meal trays at the same time the resident may feel forgotten. She stated 675053 Page 2 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0550 Level of Harm - Minimal harm or potential for actual harm she did not know why Resident #15 was not given her meal tray at the same time as her table mate. She stated the resident should have gotten her meal tray. Record Review of Dining and Meal Service Policy dated 08/01/2012 revealed individuals at the same table will be served and assisted at the same time. Residents Affected - Few 675053 Page 3 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #47) reviewed for resident rights. Residents Affected - Few The facility failed to ensure Resident #47's call light was within reach on 07/11/24. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #47's admission Record dated 07/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), dysphagia (difficulty swallowing, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of the bones wear down). Record review of Resident #47's Quarterly MDS dated [DATE] revealed a BIMS of 99 indicating Resident #47 could not complete the assessment. Section GG-Functional Abilities and Goals revealed Resident #47 was dependent with bathing, toileting hygiene, and personal hygiene . Record review of Resident #47's progress notes dated 05/13/24 revealed Hoyer for transfers, call light within reach. In an observation on 07/11/24 at 9:51 AM Resident #47's call light was on the floor and out of residents reach. Resident #47 was in bed resting quietly with eyes closed and blankets pulled up to chest area. Resident #47 opened his eyes when the state surveyor called his name but was non-verbal. Resident #47 appeared clean, groomed, and no foul odors or areas of concern were noted. Resident #47 was not in any sign of pain or distress. In an interview on 07/11/24 at 09:59 AM with MA, she stated she had been trained on call light placement. She stated she had always made sure the residents call lights were in their reach and that the residents had whatever they needed prior to leaving the residents rooms. She stated if a resident did not have their call light in reach, it could have caused an accident to happen, or the resident would not have been able to call for help. She stated the resident call lights should be in reach at all times. In an observation on 07/11/24 at 10:09 AM, Resident #47's call light remained on the floor and out of residents reach. In an interview on 07/11/24 at 10:11 AM, LVN A stated Resident #47's call light should not be on the floor. She stated call lights should always be in the residents reach and she had been trained on call light placement. She stated if a call light were not in reach that could potentially cause a resident to not be able to call for help, the resident could be in pain or distress, and could have needed help. She stated she had been trained on call light placement. 675053 Page 4 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 07/11/24 at 10:25 AM, CNA A stated she had been trained on call light placement. She stated the call lights should always be within reach. She stated if a call light were not in residents reach, a resident could have choked or could not call for help. In an interview on 07/11/24 at 10:34 AM the ADM stated staff were trained on call light placement. She stated call lights should be in place and within residents reach. She stated all staff were responsible for ensuring residents call lights were in place and within reach of residents. She stated if a call light were out of a residents reach, it could cause an incident or accident to occur. In an interview on 07/11/24 at 10:45 AM, the DON stated the nurses and CNAs were responsible for the residents call light placement. She stated staff were trained on call light placement. She stated residents call lights should always been within reach. She stated if a residents call light was not in reach, incidents could possibly happen, and the resident may not be able to call for help. 07/11/24 at 10:49 AM Requested policies for call light placement from the DON. 07/11/24 at 11:24 AM Requested policies for call light placement from the Administrator. Record review of documents given from the ADM from a book titled Clinical Nursing Skill & Techniques 10th Edition Volume 1 written by authors Perry-[NAME]-[NAME]-LaPlante revealed in chapter 14 on page 382 that residents safety begins with patient's immediate environment and call button should be in reach and call system should be easily accessible. Chapter 14 on page 383 revealed Maintain call light within reach. Chapter 18 on page 545 revealed 16. Be sure nurse call system is in an accessible location within patient's reach. Feet and nails often require special care to prevent infection, odors, pain, and injury to soft tissues. 675053 Page 5 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 6 residents (Resident # 6, Resident # 14, Resident #20, and Resident # 43) residents reviewed for personal privacy. Residents Affected - Some The facility failed to knock on Resident #6, #14, #20, and #43's room when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #6's Face Sheet dated 07/10/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6's diagnoses included senile degeneration of brain, protein deficiency, COVID, schizophrenia (mental disorder), major depressive disorder, nuclear cataract (hardening of the center part of the eye), mood disorder, abnormalities of gait and mobility, muscle wasting, expressive language disorder, muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), lack of coordination, vitamin D deficiency, cognitive communication deficit (problems with communication), Asthma (breathing difficulty), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), malaise (feeling of general discomfort), heart disease, bronchitis (inflammation in the lungs causing couch), muscle wasting, psychotic disorder with delusions, neuralgia and neuritis (severe pain due to damaged nerves), dementia (memory, thinking difficulty), type 2 diabetes mellitus with hyperglycemia (high blood sugar), solitary pulmonary nodule (small mass in the lung), anemia (not enough healthy red blood cells), hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), anxiety, insomnia (difficulty sleeping), chronic pain, chronic obstructive pulmonary disease (chronic progressive lung disease), duodenal ulcer (a break in the inner lining of the stomach), gastroparesis (delayed emptying of the stomach), scoliosis (irregular curve of the spine), muscle wasting, kidney disease, difficulty walking, abnormalities of gait and mobility, lack of coordination, and long term drug therapy. Record review of Resident #6's Quarterly MDS revealed Resident #6 has a BIMs score of 9, indicating the resident did not understand or make self-understood most of the time. Review of Resident #14's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14's diagnoses included intermediate dry stage (vision loss), open angle with borderline findings low risk (one or more eyes at risk of glaucoma), presence of intraocular lens (clear artificial lens), abnormality of albumin (problems with liver and kidney function), lack of coordination, dementia (memory, thinking difficulty), COVID, depression, dysphagia (difficulty swallowing), need for assistance with personal care, unsteadiness on feet, abnormalities of gait and mobility, hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), muscle weakness, lack of coordination, pain in left knee, type 2 diabetes mellitus without complications (high blood sugar), type 2 diabetes mellitus with chronic kidney disease (kidney disease due to diabetes), cerebral infraction (long term effects of a stroke), hypertension (high blood pressure), osteoarthritis of the knee (joint disease), and spinal stenosis (spaces inside the bones of the spine get too small). 675053 Page 6 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #14's Quarterly MDS revealed Resident #6 has a BIMs score of 2, indicating the resident did not understand or make self-understood. Review of Resident #20's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20's diagnoses included acute posthemorrhagic anemia (loss of large amount of blood quickly), hematemesis (vomiting of blood), open angle glaucoma, presence of intraocular lens (clear artificial lens), polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), COVID, reduced mobility, seizures, physical debility, hyperlipidemia (high cholesterol), lack of coordination, dysarthria and anarthria (severe speech sound disorder), need for assistance with personal care, dysphagia (difficulty swallowing), symbolic dysfunctions (development disorder of speech and language), abnormalities of gait and mobility, neuromuscular dysfunction of bladder (lack of bladder control), altered mental state, unsteadiness on feet, presence of neurostimulator (implanted device to shock the nerves), osteoporosis (skeletal disorder), pain in right shoulder, vitamin B12 deficiency, weakness, expressive language disorder, repeated falls, cognitive communication deficit (problems with communication), type 2 diabetes mellitus without complications (high blood sugar), bipolar disorder (extreme mood swings), major depressive disorder, glaucoma (eye disease), hypertension (high blood pressure), dysarthria following cerebral infraction (speech sound disorder after a stroke), rheumatoid arthritis (long term autoimmune disorder that primary affects joints), muscle wasting, and tremor (involuntary movement). Record review of Resident #20's Quarterly MDS revealed Resident #6 has a BIMs score of 10, indicating the resident could understand or make self-understood. Review of Resident #43's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43's diagnoses included disorder of bone density, overactive bladder, lack of coordination, abnormal posture, vitamin D deficiency, age related nuclear cataract (hardening of the center part of the eye), vitamin B12 deficiency, hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), hypertension (high blood pressure), embolism and thrombosis of unspecified vein (blood clots in blood vessels), constipation, pressure ulcer (bed sore), pain in joint, hematopoietic stem cell transplantation (cells that can develop into all types of blood cells ), muscle weakness, heartburn, adverse effect of antifungal antibiotics (antibiotics that don't work), feed for assistance with personal care, connective tissue and disc stenosis (spinal disease), neuromuscular dysfunction of bladder (lack of bladder control), calculus of kidneys (kidney stones), and depressive disorder . Record review of Resident #43's Quarterly MDS revealed Resident #6 has a BIMs score of 15, indicating the resident could understand or make self-understood. Observation of hall trays being passed on 07/09/2024 at 12:00pm revealed CNA C not knocking on Resident #20 or Resident #14's doors before entering the room. Observation of hall trays being passed on 07/10/2024 at 12:09pm revealed CNA C not knocking on Resident #6, Resident #14, Resident #20, and Resident # 43's doors before entering the room. An interview with CNA C on 07/11/2024 at 8:20am revealed that staff were supposed to always knock on a resident's door before entering. She stated that it was important to knock before entering because the resident could be doing something or be by the door. She stated if you do not knock, and the resident was by the door they could get hurt when you open the door. She stated that if staff did not knock on the door before entering it could cause the resident to feel like his or her privacy was 675053 Page 7 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some being invaded. She stated she was used to saying knock, knock instead of knocking. She stated it was hard to carry a meal tray with one hand and knock on the resident's door. An interview with the AM on 07/11/2024 at 8:35am revealed that she had been trained on resident rights and knocking on a resident's door before entering. She stated the policy was staff were to knock and announce themselves and wait for the resident to tell them to come in. She stated it was important to knock before entering to ensure the resident's right to privacy. She stated that if staff do not knock on the door the resident could get upset or irritated and feel as if staff were invading their privacy. The AM stated that she was not aware that she did not knock on the resident's door before entering. An interview with the DON on 07/11/2024 at 8:43am revealed she had been trained on resident rights and knocking on the resident's door before entering. She stated all staff were required to knock on the resident's door before entering their room. She stated it was important to knock for the resident's rights and privacy. She stated that if staff did not knock on a resident's door the resident could feel like they were not being respected or their privacy was being invaded. She stated that one staff did not knock on the resident's door because she was worried about dumping the tray. She stated the staff still should have knocked on the door. An interview with the ADM on 07/11/2024 at 8:54pm revealed staff were supposed to knock before entering a resident's room. She stated all staff and visitors were supposed to knock before entering a resident's room. She stated that it was important to knock before entering to ensure the resident's right for privacy was not being violated. She stated that if staff did not knock on the door before entering the resident might have felt like staff were not respecting their rights. She stated that some staff would say knock, knock but staff should be knocking. An interview with Resident #43 on 07/11/2024 at 8:58am revealed that most of the time staff knock on the resident's door. She stated it does not bother her. Resident #43 also stated that there are times staff do not know and most the time she does not even notice staff did not knock. An interview with Resident #14 on 07/11/2024 at 9:01am revealed that sometimes staff knock. She stated she would like for staff to knock every time. She stated she did not know how she felt about staff not knocking. Record review of DMS Policy & Procedure Review of Residents' Rights dated 05/01/2012 revealed: When must you knock and ask permission to enter a resident's room? Always to protect their right to privacy. A possible exception may be when the resident is in a life-threatening situation and/or unable to respond. 675053 Page 8 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one resident (Resident #57) out of five residents reviewed for activities of daily living received care and services for nail care. Residents Affected - Few The facility failed to ensure that Resident #57's fingernails and/or toenails were cleaned and trimmed. This failure placed residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life. Findings included: Record review of Resident #57's admission Record dated 07/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart, dementia (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities), dysphagia (difficulty swallowing), and bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. Record review of Resident #57's Comprehensive Care Plan dated on 01/18/24 revised on 06/24/24 revealed a focus Resident #57 required assistance to complete ADLs, level of assistance may vary depending on my condition with interventions that include nail, hair, and oral care daily and as needed. Record review of Resident #57's Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating cognitive skills for daily decision making were moderately impaired. Section E-Behavior revealed Resident #57 did not resist ADL care that was necessary to achieve the resident's goals for health and wellbeing. Section GG-Functional Abilities and Goals revealed Resident #57 needed partial/moderate assistance with bathing and toileting hygiene, Resident #57required supervision or touching assistance for personal hygiene. Record review of Resident #57's progress notes dated 06/22/24 revealed Resident is dependent on staff for most ADL's due to weakness in lower extremities. In an observation on 07/11/24 at 9:29 AM Resident # 57's fingernails were jagged, slightly long, and dirty. Fingernails contained a moderate amount of a thick brown substance underneath each fingernail. In an interview on 07/11/24 at 09:30 AM, Resident #57 stated that he asked a staff member a week ago to clean and trim his nails. He stated he did not remember who the staff member was, but she had told him that a foot doctor would have to clip his nails because he was diabetic. He stated he had not seen a foot doctor since he had been in the facility that he remembered. He stated someone had clipped and cleaned his nails before in the facility about a month or two ago but that was the last time he remembered. He stated the staff had seen that his nails were dirty when he asked them to trim them, but they still did not clean them, and the staff did not clean his nails when he took a shower. In an interview on 07/11/24 at 09:59 AM, the MA stated CNA's were responsible for the residents 675053 Page 9 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nail care and they checked residents nails often. She stated if a resident's nails were too long or dirty, then the CNA's should have trimmed and cleaned the nails. She stated if a resident was diabetic the CNA should have told the nurse and the nurse should have taken care of the resident's nails. She stated she had been trained on ADL's, cleaning, and trimming resident's nails. She stated if a resident's nails were too long or dirty, it could cause possible cross contamination. She stated resident's nails should always be cleaned and trimmed. In an interview on 07/11/24 at 10:11 AM, LVN A stated if a resident was diabetic, the nurses were responsible for clipping the resident's nails. She stated if staff saw a resident's nails and they were dirty or needed to be trimmed, they should have cleaned or trimmed the resident's nails or informed the nurse that was responsible for the resident. She stated if a resident's nails were too long or dirty, it could cause a risk of infection. She stated she had been trained on ADL care and nail care. In an interview on 07/11/24 at 10:25 AM, CNA A stated resident's nails were cleaned when they were in the shower. She stated she had been trained on ADL's and nail care. She stated if a resident had dirty or long nails and they were diabetic, she would tell the nurse. She stated it was not acceptable for a resident to have dirty or too long nails and it could cause all kinds of infections or could have made a resident sick if their nails were not clean. In an interview on 07/11/24 at 10:34 AM, the ADM stated staff were trained on ADL's, cleaning, and trimming nails. She stated resident's nails should have been cleaned and trimmed as needed and the nursing staff were responsible for that. She stated resident's nails should have been cleaned and trimmed as needed and resident should have never been left with feces under their nails or have dirty nails. She stated if a resident's nails were dirty or too long it could cause a negative outcome such as possible infections or dignity issues. In an interview on 07/11/24 at 10:45 AM, the DON stated the nurses and CNA's were responsible for the residents nail care. She stated staff were trained on ADL's and nail care. She stated residents should never have had dirty or nails that were too long or jagged. She stated if a resident was eating and had dirty or too long nails it could cause transfer of bacteria, or the resident could get sick. 07/11/24 10:49 AM Requested policies for ADL care and nail care from the DON. 07/11/24 11:24 AM Requested policies for ADL care and nail care from the Administrator. Record review of documents given from the ADM from a book titled Clinical Nursing Skill & Techniques 10th Edition Volume 1 written by authors Perry-[NAME]-[NAME]-LaPlante revealed in chapter 18 on page 546 revealed The best time to perform nail and foot care is during a patient's daily bath. 675053 Page 10 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 6 residents (Residents #10, Resident #60, Resident#131, and Resident #39) reviewed for the usage of wrist blood pressure monitor. Residents Affected - Some LVN C and LVN D did not clean and disinfect the wrist blood pressure monitor while using it on Resident #10, Resident # 39, Resident #60, and Resident #131. This failure could place the residents at the facility at risk of transmission of disease and infection. Findings included: Review of Resident #10's face sheet dated 07/10/24 reflected, Resident #10 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with hypertension, atherosclerotic heart disease (plaque buildup in the artery walls), anemia, coronary artery disease (insufficient supply of blood to heart), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms), chronic obstructive pulmonary disease (breathing difficulty), dysphagia (difficult to swallow), urinary tract infection, and arthritis (swelling and tenderness of one or more joints). Record Review of Resident #10's MDS dated [DATE], reflected she was admitted on [DATE] and the MDS was still in progress. Record Review of Resident #10's care plan dated 07/10/24 revealed she had impaired cardiovascular status related to coronary artery disease, hypertension, and peripheral vascular disease and the relevant intervention was observing for abnormal vital signs and report. Review of Resident # 10's MAR for July 2024, reflected: Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate): Give 0.5 tablet by mouth two times a day for blood pressure. Hold medication for BP below 110/55 or pulse below 55. Review of Resident #39's face sheet, dated 07/10/24, reflected Resident #39 initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with hypertensive heart disease, cerebral palsy (conditions that affects posture and movements), dysphagia (difficult to swallow), speech disturbances, cognitive communication deficit, muscle wasting, slurred speech, abnormalities of gait and mobility, lack of coordination, hyperlipidemia (high fat level), unsteadiness on feet, and hypothyroidism (low thyroid hormones). Record Review of Resident #39's annual MDS assessment dated [DATE], reflected he had a BIMS score of 13, indicating his cognition was intact. Record Review of Resident #39's care plan dated 07/10/24 revealed, impaired cardiovascular status related to hypertension, hypothyroidism, and hyperlipidemia and relevant intervention was observing 675053 Page 11 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0880 for abnormal vital signs and report. Level of Harm - Minimal harm or potential for actual harm Review of Resident # 39's MAR for July 2024 reflected: Propranolol HCl Tablet 40 MG: Give 1 tablet by mouth two times a day for BP. Residents Affected - Some An observation of taking blood pressure using a wrist blood pressure monitor on 07/10/24 at 9:20 am revealed LVN C failed to sanitize the wrist blood pressure monitor after using it on Resident #10 and before using it on Resident #39. LVN C took the blood pressure of Resident #10 with the wrist blood pressure monitor and without sanitizing the monitor she kept it on the top of the medication cart. After administering the medications to Resident #10, she moved on to Resident #39 and used the same blood pressure monitor on him without sanitizing it. During an interview on 07/10/24 at 10:05 am LVN C stated she was aware of the necessity of sanitizing the blood pressure wrist monitor after every use on the residents. LVN C said she practiced this her whole career as a nurse however forgot to do it on that day. She stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. LVN C stated she received trainings on infection control quite often however could not remember if there was any in-services specifically related to sanitation of medical equipment. Review of Resident #60's face sheet, dated 07/10/24, reflected Resident #60 initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with dementia, chronic obstructive pulmonary disease (difficulty to breath), hypertension, peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms), cardiac murmur, cognitive communication deficit. and hyperlipidemia, Record Review of Resident #60's Quarterly MDS assessment dated [DATE], reflected he had a BIMS score of 06, indicating severe cognitive impairment. Record Review of Resident #60's care plan dated 07/10/24 revealed she had impaired coronary artery disease, hypertension, and peripheral vascular disease and the relevant intervention was observing for abnormal vital signs and report. Review of Resident # 60's MAR for July 2024 reflected: 1.Carvedilol Oral Tablet 25 MG (Carvedilol) Give 1 tablet by mouth two times a day related to Essential (primary) Hypertension hold SBP < 110 DBP <60 HR <60. 2. Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 1 tablet by mouth one time a day related to Essential. (primary) Hypertension, Hold SBP < 110 DBP <60 HR <60. Review of Resident #131's face sheet, dated 07/10/24, reflected Resident #131 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with dementia, type 2 diabetes, chronic obstructive pulmonary disease (disease causes labored breathing) , hypertension, congestive heart failure ( Heart fails to function properly) , rheumatoid arthritis (autoimmune disease that affects mostly the joints) , and major depressive disorder. 675053 Page 12 of 13 675053 07/11/2024 Chisolm Trail Nursing and Rehabilitation Center 107 N Medina Lockhart, TX 78644

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #131's Initial MDS assessment dated [DATE], reflected he had a BIMS score of 03, indicating severe cognitive impairment. Record Review of Resident #131's care plan dated 07/10/24 revealed she had impaired congestive heart failure, coronary artery disease, and hypertension and the relevant intervention was observing for abnormal vital signs and report. Review of Resident # 131's MAR for July 2024, reflected: Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 1 tablet by mouth one time a day for HTN hold for SBP less than 110 or DBP less than 55. HR less than 55. An observation on 07/10/24 at 10:40 AM revealed, while taking blood pressure using a wrist blood pressure monitor LVN D failed to sanitize the wrist blood pressure monitor before and after using it on Resident #60 and Resident #131. LVN D took the blood pressure of Resident #60 with the wrist blood pressure monitor. She did not sanitize the monitor prior to using it on Resident #60. After the completion of taking blood pressure and medication administration to Resident #60, she moved on to Resident #131 and took blood pressure with the unsanitized blood pressure cuff. During an interview on 07/10/24 at 1:15PM, LVN D stated sanitizing blood pressure cuffs in between the residents was important. She continued, mistakes could happen with anyone and the best way to resolve it was learning from their mistakes. LVN D stated following infection control protocol was important to minimize spreading diseases from one resident to another. LVN D stated she received trainings on infection control two weeks ago and there were no in-services on sanitizing medical equipment. During an interview on 07/11/24 at 11:00AM the DON stated she started working as the DON at the facility on 07/09/24. She stated her expectation was the nursing staff following facility policy/procedure for handwashing and sanitization of medical equipment that included sanitizing the blood pressure monitor every time after the use on residents. She added, this was essential to stop spreading transmittable diseases. During an interview on 07/11/24 at 11:00AM the IP stated she did audit rounds quarterly covering all the activities at the facility and based on the observed deficiency the training programs developed. She stated sanitizing medical equipment in between residents was mandatory since a compromise in this would spread diseases. She stated she conducted most of the in-services and did not remember if any inservice specific to sanitizing medical equipment was conducted. Review of facility's policy titled Equipment and department cleaning/Maintenance Policy dated April,2020 reflected: Each piece of equipment used for patient/resident care is to be cleaned with a center approved surface disinfectant before and after each patient use. This includes, but not limited to wheelchairs, blood pressure cuffs, glucometers, temperature probes, lifts, all therapy equipment, shower chairs, bedside tables, and scales Equipment should not be used between patients without being appropriately disinfected . 675053 Page 13 of 13