Health inspection·March 21, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for five of five residents reviewed for resident council. Residents Affected - Some The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Included: In an interview on 03/19/2024 at 10:12 am, the Activity Director when asked to set up Resident Council meeting revealed the Resident Council meetings were held in the dining room. She stated there was not another area for the residents to meet in private. She stated she would place signs on the privacy curtain. She stated she would notify staff before the meeting not to come in or out of the dining room until after the resident group meeting. The Activity Director offered to move the Resident Council meeting to her office so it would be private. In an interview on 03/20/2024 at 10:15am, during a confidential resident group meeting held in the Activity Director's office with five residents revealed their meetings were normally held in the dining room. The residents in attendance of the resident group meeting stated interruptions occurs every- time they had a Resident Council meeting. Residents in the meeting stated that it was disrespectful and that they had informed the Administrator several times, but staff continued to interrupt their council meetings. The residents in the meeting stated they would like some place private to meet. In an interview with the Activity Director on 03/21/2024 at 8:43am revealed that the resident council normally meets in the dining room. She stated she has signs that she puts on the curtain and tells staff they were not to go into the dining room until the meeting is over. She did not say she does anything to prevent the staff from coming in the dining room. She stated that the residents were supposed to have a private place to meet. She stated that they have asked for a more private place, but the facility did not have anywhere else big enough for them to meet. She stated that residents may feel like the facility was not respecting them or the resident may lash out if staff interrupted their meetings. She stated that when staff have interrupted, they would talk to them and inform them that they are not to go into the dining room when the residents are having their meeting. The Activity Director stated she has been trying to get a private place for the residents to meet. In an interview with the Administrator on 03/21/2024 at 11:32am revealed the residents had the Page 1 of 15 675075 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some right to meet in a private area, and someone must be invited to attend the meeting. He stated the residents may not feel comfortable voicing their concerns. He stated the facility was small and not a lot of room and that he was finding a private place for the residents to meet. Record Review of the Resident Council Policy dated 5/1/2012 revealed it is the responsibility of the Activity Director/Social Services Designee to provide the Resident Council with a private place to meet. 675075 Page 2 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of six residents (Resident # 26, Resident #32, and Resident #140). Residents Affected - Some 1. The facility failed to ensure Resident #26's facial hair was removed. 2. The facility failed to ensure Residents # 32's and #140's nails were cleaned and trimmed. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1.Record review of Resident #26's face sheet dated, 03/21/2024 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction, unspecified (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), aphasia (unable to comprehend or unable to formulate language because of damage to specific brain regions), and muscle weakness ( a lack of strength in the muscles). Record review of Resident #26's Quarterly MDS assessment, dated 11/09/2023, reflected Resident #26 was never/ rarely understood and was not capable of completing the BIMS questions. Her cognitive patterns were assessed by the staff. Resident #26 had poor short- and long-term memory recall. Resident #26 was dependent on the staff for ADLs including personal hygiene. Record review of Resident #26's Comprehensive Care Plan, dated 03/04/2024 reflected she was rarely/ never understood. Interventions: Anticipate resident needs. Use simple and direct communication to promote understanding. Resident #26 had neurological status (overall condition of the nervous system function) related to aphasia (unable to comprehend or unable to formulate language because of damage to specific brain regions) CVA (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) Intervention: Resident #26 required ADL assistance. Render care as needed. Observation on 03/19/2024 at 9:58 AM revealed Resident #26 was in bed. She had approximately 3-4 inches of white strands of hair on her chin and on both of her cheeks. Interview on 03/19/2024 at 10:00 AM revealed Resident #26 was not interviewable. Interview via telephone on 03/20/2024 at 9:49 AM Resident #26's family member stated she had reported to staff about the facial hair on Resident #26's face. She stated she did not recall when or who she spoke to about her concern of the facial hair. She also stated the staff had time before 03/20/2024 to remove the facial hair on Resident #26. 2. Record review of Resident #32's face sheet, dated 03/20/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete loss of movement on one side of the body - hemiparesis is diminished strength, without total paralysis), unspecified lack of coordination ( 675075 Page 3 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0677 Level of Harm - Minimal harm or potential for actual harm muscle control problem that causes an inability to coordinate movements), muscle wasting and atrophy, not elsewhere classified, multiple sites ( the loss of muscle mass and strength due to a lack of physical activity or a condition that affects the muscles or nerves), diabetes (elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, and kidneys), and unspecified dementia ( affects memory, thinking and social abilities). Residents Affected - Some Record review of Resident #32's admission MDS Assessment, dated 03/08/2024, reflected Resident #32 had a BIMS score of a 7 which indicated his cognition was moderately impaired. Resident #32 did not refuse care. He required assistance with ADLs. Resident #32 required supervision or touching assistance with personal hygiene. Record review of Resident #32's Comprehensive Care Plan dated 03/15/2024 reflected Resident #32 had self-care deficit related to hemiplegia to right side (paralysis of the right side of the body), CVA (poor blood flow to the brain) and impaired cognition (a condition where a person has problems with memory, learning, concentration, or decision making). Interventions: Provide supervision and touching assistance with personal hygiene. Resident #32 had diabetes mellitus. Intervention: nails should always be cut straight across, never cut corners, file rough edges with emery board. Observation on 03/19/2024 at 10:54 AM revealed Resident #32 was sitting in his room watching television. The tips of his nails were not trimmed evenly, and his nails were approximately 2 inches long from the top of his fingers on his right hand. Resident #32 had blackish/brownish substance underneath all his nails on his left and right hand. Interview on 03/19/2024 at 10:56 AM Resident #32 stated he asked someone to cut his fingernails, they were rough and not straight. He also stated he asked someone to clean his nails because he did not know what the black stuff was underneath his fingernails. Resident #32 stated he did not recall the name of the person who trimmed and clean his fingernails. He stated he wished someone would trim and clean them because they were dirty. He stated he was afraid to do it because in the past when he cleaned or trimmed his nails his fingernails had green stuff running out of the side of his fingernail. He stated he went to the doctor, and they told him his finger was infected. Resident #32 stated the infection of his finger happened when he lived at home. Interview and observation on 03/20/24 08:00 AM Resident #32 stated my nails are still dirty. They need to be cleaned; can you get someone to clean them sometime this week. I asked few times, and no one has cleaned my nails He stated he did not recall who he asked to clean nails and trim them His nails were dirty underneath all his nails on both hands. Observation on 03/20/2024 at 8:00 AM revealed Resident #32 was in his room lying in bed. His fingernails were still long and rough around the edges of the nails. There were not any changes in his nails since 03/19/2024 at 10:54 AM. The tips of his nails were not trimmed evenly, and his nails was approximately 2 inches long from the top of his fingers on his right hand. Resident #32's nails had blackish/brownish substance underneath all his nails on his left and right hand. Interview on 03/20/2024 at 8:05 AM Resident #32 stated he did ask someone yesterday (3/19/2024) to cut and clean his nails and they said a nurse would need to clean and trim his nails. He stated no one came to his room on 3/19/2024 to clean or cut his nails. He stated he could try to find something and do it himself, but he was afraid of getting his fingers infected. 3. Record review of Resident #140's face sheet, dated 03/20/2024, reflected Resident #140 was a 675075 Page 4 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0677 Level of Harm - Minimal harm or potential for actual harm [AGE] year-old female admitted to the facility on [DATE] with diagnoses included lymphedema (swelling due to build-up fluid in the body), essential hypertension (high blood pressure that is not due to another medical condition), and hyperlipidemia (high level of lipids -like cholesterol in your blood). Residents Affected - Some Record review of Resident #140's MDS admission Assessment revealed it was in progress. Record review of Resident #140's Baseline Care Plan dated 03/17/2024 reflected Resident #140 needed to improve ADL independence. Resident #140 also had barriers to transition such as: bathing, safety awareness, and self-care. Observation on 03/19/2024 at 11:45 AM revealed, Resident #140 was sitting in the small dining room with other residents. Resident #140's nails were approximately 2-3 inches long (from the tip of her finger) on her right and left hand. She had blackish substance underneath all nails on both hands. Interview with Resident #140 on 03/19/2024 at 11:48 AM she stated she wished someone would cut and clean her nails, they looked bad, and she was embarrassed for anyone to see her dirty nails. She stated she did ask someone to clean them but did not recall their name. She stated she was new at the facility and did not know anyone. Observation on 03/20/2024 at 8:30 AM revealed Resident #140's fingernails had not been trimmed or cleaned since observation on 03/19/2024 at 11:48 AM. Resident #140's nails was approximately 2-3 inches long (from the tip of her finger) on her right and left hand. She had blackish substance underneath all nails on both hands. Interview on 03/20/2024 at 8:33 AM Resident #140 stated she thought she had asked someone to cut her nails and clean her nails yesterday and when she came to this place (facility). She stated she was new and did ask someone to cut and clean her nails but did not recall the person's name. Resident #140 stated her nails looked bad and she did not have anything to clean her nails, or she would try to cut and clean her nails. In an interview on 03/21/24 at 08:35 AM CNA A stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA A stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA A stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated a resident may need to be assessed at the emergency room if they became severely ill. CNA A also stated if a female resident had facial hair on their face, it was the nursing staff responsibility to remove the hair with tweezers or a razor whichever the resident preferred. CNA A stated if a female resident had facial hair the resident may not want to come out of the room or be around others due to being embarrassed of her appearance. She stated she had been in-serviced on cleaning nails and removing facial hair on ladies. She stated Residents #26, Resident #32 and Resident #140 did not refuse care. In an interview on 03/21/2024 at 08:53 AM, the Administrator stated it was the CNA'S responsibility to do nail care. He stated nail care was expected to be completed during showers and/or as needed. 675075 Page 5 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some He also stated any resident with a diagnosis of diabetes it was expected that their nails would be trimmed/cut by a nurse. The Administrator stated a resident had a potential of ingesting bacteria into their mouth. He stated there was a possibility a resident may become ill such as vomiting or diarrhea if the black substance was some type of bacteria. The Administrator stated if a female had facial hair, the nursing staff was responsible to remove the facial hair with tweezers. He also stated for a female with facial hair there was a possibility the female may be embarrassed for other people to see her and could be a dignity issue. The Administrator stated the charge nurse was responsible of monitoring the CNAs to ensure personal hygiene was completed daily. Interview on 03/21/24 at 9:22 AM CNA B stated it was the nurses and the CNAs responsibility to trim, cut, and clean residents' fingernails. She stated only the nurses can trim and clean residents with a diagnosis of diabetes. CNA B stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth there was a possibility the feces could transfer from their fingers to their mouth. She also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach problems and resident may become dehydrated and the resident may need to be treated at the emergency room. She stated the symptoms of a stomach infection may include the following: diarrhea or vomiting. She stated if a female had facial hair, the facial hair was expected to be trimmed during showers or as needed. She stated a female may not want other people to look at them with hair on their face. CNA B stated a female resident may isolate themselves in their room due to being embarrassed. She also stated the CNAs completed nail care during showers and the CNAs would notify the nurses at that time if a resident with diagnosis of diabetes needed any nail care completed. She stated she had been in serviced on nail care and trimming female facial hair. She could not recall the last time she was in serviced. CNA B stated in the in-service it covered doing nail care on residents in the shower and as needed. Interview on 03/21/24 at 09:50 AM LVN C stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNA's responsibility to clean and trim all other residents' nails. LVN C stated the CNAs report to nurses of any diabetic resident's nails to be cleaned. She stated the nurses makes rounds and check residents, with diabetes, nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. LVN C stated if a female resident had facial hair the CNAs was expected to remove the facial hair with tweezers and if it was thick facial hair the CNA was to report to the nurse and the nurse would determine how to remove the hair without causing pain to the resident. She stated a female resident may be embarrassed to be around other people if they had facial hair and the resident may develop low self-esteem. She stated if a resident was not able to express, they wanted the hair removed and the family requested the hair to be removed the staff should remove the hair as soon as possible after the family made the request. She stated she had been in serviced on nail care but did not recall the date of the in-service. In an interview on 03/20/2024 at 10:33 AM, the Director of Nurses stated resident's nails were expected to be trimmed on Sunday's, during shower days, or as needed. She stated if a resident had blackish substance underneath the nails and the resident 675075 Page 6 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. The director of nurses stated if staff see a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. She stated if a female resident had facial hair it was expected to be remove immediately with tweezers or how the resident preferred the hair to be removed. She stated some female residents preferred the hair to be removed with a razor. She stated if a resident was not able to express how they wanted it to be remove or ask for the hair to be removed but the family requested it the staff would ask the family their preference of how they prefer the hair to be removed. She stated if a resident unable to express they have facial hair, and the family knows the resident did not want facial hair. The nurse supervisor was responsible to monitor the nail care and ensure residents were getting personal care. Record review of the facility's Performing Nail Care (undated) reflected the best time to provide nail care was during a patient's bath. Record review of the facility's policy on Hygiene (not dated) reflected prior to implementing any nail care, use clinical judgment to assess and analyze data about any existing or at-risk nail problems. Record review of all the CNAs Competency and Skills Checklist (dated on the hire date of each CNA) reflected the CNAs was trained on nail care, hair care and shaving male and females. 675075 Page 7 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

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 prepared puree food by methods that conserve nutritive value, flavor, and appearance as evidence by mixing the hamburger meat with water The extent is no actual harm with the possibility of more than minimal harm. Residents Affected - Few The puree diet hamburger meat was mixed with water instead of thickener or a broth with nutrient value. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. Findings include: Observation on 03/19/2024 at 11:35am revealed CK F pureed hamburger meat with water instead of the thickener on the counter. CK F did not have any recipes out for puree Interview with the Dietary Manager on 03/20/2024 at 1:45pm revealed that CK F was filling in from another facility and the Dietary Manager was not sure what training she had. She stated that when doing puree staff were to follow the puree recipe. The Dietary Manager revealed she is responsible for overseeing puree in the kitchen. She stated that she thought that CK F was trained and knew what to do. She stated if she knew CK F did not know puree she would have just done it herself. She stated staff were never supposed to mix water in puree food because it takes away the nutrients in the food. She stated that she did not realize that CK F mixed water in the puree until after it was served. Interview with CK F on 03/20/2024 at 2:44pm revealed that she had been trained on puree diets. She stated that she normally mixed the puree with broth, orange juice or milk. CK F stated that she got nervous and forgot everything. She stated she realized after that she mixed the hamburger meat with water. She stated that mixing the puree with water takes the nutrients away from the food. She stated by taking the nutrients away from the food it puts the resident at risk of weight loss or other health issues. Record Review of the Essential Functions of the Job no date revealed staff prepare food by methods that conserve nutritive value and flavor. 675075 Page 8 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the physician prescribed therapeutic diet to 1 of 8 residents (Resident #3) reviewed for therapeutic diets, in that: Resident #3 was given salt when her meal ticket stated no added salt as ordered. This failure could place residents at risk for further health issues. Findings included: Record review of Resident #3's face-sheet dated 03/212024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Atrial fibrillation, stiffness of left hand, dehydration, hyperkalemia, personal history of urinary tract infections, hallux varus acquired left foot, stiffness of right hand, muscle wasting, contracture right hand, allergies, history of falling, never pain, age related disability, inner ear infections right ear, age related cognitive decline, difficulty in walking, unsteadiness on feet, unspecified abnormalities of gait and mobility, chronic obstruction pulmonary disease, heart failure, high levels of fat particles in blood, arthritis, high blood pressure, heart disease of coronary artery, contractors to fingers and thumb, muscle weakness, and lack of coordination. Record review of Resident #3's dietary orders dated 07/24/2023 revealed she was on a regular diet with no salt added. Observation of lunch on 03/19/2024 at 12:19pm revealed Resident #3's meal ticket stated she was on a regular diet no added salt. Resident #3 also had physician orders dated 07/24/2023 that stated resident was a no salt added. Resident #3 was given a salt packet with her meal. Interview with Resident #3 on 03/19/2024 at 2:10pm revealed that Resident #3 was on a no salt diet. Resident #3 stated that they give her salt all the time, but she does not use the salt. She stated that she knows she was not supposed to have salt. Observation of Breakfast on 03/21/2024 at 8:54am revealed Resident #3 was given salt with her breakfast. Interview with DA D on 03/21/2024 at 8:56am revealed that she put the condiments on the trays. DA D stated that she had been trained on therapeutic diets and how to read the dietary meal tickets. She stated that she was not aware of Resident #3's diet being a no salt diet. She stated she did not see the no salt on the meal ticket that she missed it. She stated the negative outcome could be the resident have a reaction to something if they were not supposed to have the food item. Interview with the Dietary Supervisor on 03/21/2024 at 9:09am revealed the aides were responsible for checking to ensure the trays are correct before leaving the kitchen. She stated that the nurses were also supposed to check the tray before it gets to the resident. She stated she was not sure why the resident received salt when it said on the meal ticket no salt. She stated the resident could have a reaction if not given the correct diet. 675075 Page 9 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0808 Level of Harm - Minimal harm or potential for actual harm Interview with LVN C on 03/21/2024 at 9:34am revealed that the nurses check the trays once they were put on the cart. She stated the condiments were usually clumped together and she was bad about checking the condiments also. She stated if a resident were to get the wrong diet or condiment the resident could have edema, end up in the hospital, all kinds of potential issues. LVN C stated she was not sure who checked Resident #3's tray. Residents Affected - Few Interview with RN E on 03/21/2024 at 10:45am revealed that the nurses were supposed to check meal trays before they were given to the residents. RN E stated they check to ensure the diet was correct and matches the meal ticket. She stated if the diet was not correct, they send it back to the kitchen to be corrected. She stated that if a resident were given the wrong diet, it could cause different health issues depending on the diet. She stated she was not sure who gave Resident #3 her tray or who checked the tray. She also stated the DON and MDS nurse were checking the trays. Interview with the DON on 03/21/2024 at 11:01am revealed that the nurses were to check the trays before giving them to the residents. She stated the nurses check the trays to ensure the resident was getting the correct diet. She stated that if the diet was not correct the resident could choke if given thin liquids instead of thick liquids that were ordered. The DON stated she was not checking trays this morning that the MDS nurse was. She stated the dietary staff usually puts the condiments on the trays automatically. She stated she was not sure if they give residents salt on a regular basis when the resident was not supposed to have salt. Interview with the MDS nurse on 03/21/2024 at 11:12am revealed that the nurses were to check the trays before giving to the residents. Stated there could be several issues with a resident not getting the proper diet. She stated it would depend on if the diet were therapeutic and a resident was not supposed to get sugar because he/she are diabetic it could cause his/her blood sugar to rise. She stated she did check the trays in the morning, but she did not check Resident #3's tray because she came late to breakfast. The MDS nurse stated she was not sure if anyone checked Resident #3's tray. Record Review of Essential Functions of the Job for the Dietary Supervisor (no date) revealed review tray card to assure the current food information is consistent with foods served. Inspect special diet trays to ensure that the correct diet was served to residents. 675075 Page 10 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

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 foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure employees were sanitizing their hands in between tasks. This failure placed residents at risk of foodborne illness. Findings included: Observation of the kitchen on 03/19/2024 at 11:35am revealed CK F did not sanitize or wash her hands after getting the Puree blender from the dishwasher. CK F also did not change her gloves or sanitize or wash her hands after taking the hamburger meat out of the oven. It was also revealed that CK F picked up the pan the hamburger meat was in and folded up the paper liner and threw it away and did not change her gloves afterwards. Observation of CK F on 03/20/2024 at 10:35am revealed that CK F pureed the ham and touched the outside of the recipe manual and touched the recipe pages. CK F continued to puree the ham after touching the recipe manual and pages without changing her gloves. CK F proceeded to move from the prep table and open the oven door and back to the area where she was pureeing the ham. She placed her fore finger and middle finger on her right hand in the container of the puree ham. CK F did not change her gloves between tasks. Interview with the Corporate Dietary Manager on 03/20/2024 at 10:55am revealed CK F was expected to change her gloves after she touched the recipe manual. The Corporate Dietary Manger stated when the cook touched the oven door and the recipe manual CK F was to remove her gloves and wash her hands and place new gloves on. She stated the oven door, and the manual were considered contaminated. Interview with the Dietary Manager on 03/21/2024 at 9:09am revealed she was responsible for all staff in the kitchen and overseeing that they were following policy and procedures. She stated staff had been trained on how to wash their hands and when they should wash their hands. She stated that staff were to wash their hands after each task to prevent cross contamination. The Dietary Manager stated failing to wash or change gloves after each task could put the residents at risk of getting sick. She stated that hand washing is covered every month with the kitchen staff. Interview with the Administrator on 03/21/2024 at 11:32am revealed all staff had been trained on hand hygiene. He stated that hand hygiene was covered monthly. He stated that they cover with staff how long they were to wash their hands, how often, the twenty second rule and the reason. The Administrator also stated that he expects all staff to follow the policy. He stated if staff do not wash their hands or change their gloves then it could cause residents to get sick or spread infections. Record Review of the Food Preparation Policy dated 2/2023 revealed all staff will practice proper hand washing techniques and glove use. Record Review of facility policy titled Hand Hygiene Steps no date that is covered with staff revealed the following: 675075 Page 11 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0812 When decontaminating hands with an alcohol-based hand rub: Level of Harm - Minimal harm or potential for actual harm Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Residents Affected - Many Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. 675075 Page 12 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

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 Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of 3 of 3 residents (Resident #10, Resident #26, and Resident #30) reviewed for infection control in that: Residents Affected - Some CNA G and Speech Therapist did not sanitize or wash hands after touching contaminated items before feeding resident or touching residents' food placing residents at risk of food contamination This failure could place all residents at risk of getting sick from staff not performing proper hand hygiene. The findings were: Record review of Resident #10's face-sheet dated 03/21/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Atrial fibrillation, cognitive communication defect, history of falling, diarrhea, lack of coordination, under immunization status, urinary incontinence, abnormal levels of serum enzymes, vitamin D deficiency, constipation, too little calcium in the blood, high levels of fat particles in blood, high blood pressure, heart disease of coronary artery, kidney failure, anemia, heart failure, absence of left leg below the knee, type 2 diabetes. Record review of Resident #26's face-sheet 03/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia with other behavior disturbance, bunion on foot, vitamin D deficiency, lack of coordination, infection of skin, abnormal posture, urinary tract infection, history of COVID 19, muscle wasting, insomnia, high blood pressure, difficulty swallowing, difficulty communicating, stroke, repeated falls, and curvature of the spine. Record review of Resident #30's face-sheet 03/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia with agitation, chronic constipation, overactive thyroid, difficulty speaking after a stroke, repeated falls, acute heart disease, and depression. Observation of dining services on 03/19/2024 at 12:16pm revealed the Speech Therapist wiped her nose with her right hand. She then picked up the ground fruit cocktail bowl beside Resident #10's plate. When she picked up the fruit cocktail bowel her right ring finger and her middle finger touched inside the bowl. The Speech Therapist used her ring finger on her right hand to wipe her nose. She did not use a Kleenex or wash her hands before touching Resident #10's fruit cocktail bowel. Observation of dining services on 03/19/2024 at 12:21pm revealed CNA G touched her clothes with her right hand and proceeded to cut Resident #30's hamburger placing her whole palm of her right hand on the top bun and cutting into fourths. CNA G did not wash or sanitize her hands after touching her clothing. CNA G than touched the carpet looking material on the column in the small dining room that had a brown stain on it. CNA G then touched her clothing again. She then proceeded to roll a chair from behind the nurses' station to the small dining room beside Resident #26. CNA G touched a regular chair back and the arms of the two different wheelchairs. CNA G did not was or sanitize her hands after any of the mentioned tasks. CNA G did not sanitize or wash her hands and proceeded to touch the hands of two residents. CNA G sat to feed Resident #26 and cut the resident's burger placing her hand on the hamburger bun while cutting it. She still did not sanitize or wash her hands. CNA G fed 675075 Page 13 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0880 Resident #26 the hamburger that she touched with her right hand. Level of Harm - Minimal harm or potential for actual harm Interview with CNA G on 03/21/2024 at 9:31am revealed she had been trained on hand hygiene. She stated that staff were supposed to wash their hands before they touch a tray, anytime they touch something or their clothing. CNA G stated that if staff do not wash or sanitize their hands before touching a tray or after touching something they could cause contamination of the food and the residents could get sick. She stated she did not realize she had not sanitized her hands before touching Resident #26 and Resident #30's food. CNA G stated she wanted to get Resident #26's food cut so she could start eating. Residents Affected - Some Interview with the Speech Therapist on 03/21/2024 at 9:40am revealed that she was trained on hand hygiene. She stated that staff were supposed to wash their hands after every resident and not touch food until you have washed your hands. The Speech Therapist stated that if staff do not wash their hands infections can spread. She stated she did not realize that she had wiped her nose and then touched Resident #10's fruit cocktail. She said that her allergies were bad and if she did not wipe her nose would drip. She stated that she knew better then to not wash her hands after touching her nose. Interview with the Administrator on 03/21/2024 at 11:32am revealed all staff had been trained on hand hygiene. He stated that hand hygiene was covered monthly. He stated that they cover with staff how long they were to wash their hands, how often, the twenty second rule and the reason. The Administrator also stated that he expects all staff to follow the policy. He stated if staff do not wash their hands or change their gloves then it could cause residents to get sick or spread infections. Record Review of the Infection Control Standard Precautions Policy dated 2022 revealed standard precautions are recommended practice for the care of all patients and residents receiving care in the facility. Standard Precautions include hand hygiene before and after patient/resident contact including after gloves are removed. Record Review of the facility policy titled Hand Hygiene Steps no date reviewed with staff revealed the following: When decontaminating hands with an alcohol-based hand rub: Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. 675075 Page 14 of 15 675075 03/21/2024 Diversicare of Luling 208 Maple St Luling, TX 78648

F 0880 Rinse hands with water and dry thoroughly with a disposable towel. Level of Harm - Minimal harm or potential for actual harm Use towel to turn off the faucet. Residents Affected - Some 675075 Page 15 of 15