Health inspection·February 3, 2023

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 observation, interview, 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 promotes maintenance or enhancement of his or her quality of life for two of six residents (Resident #26 and Resident #223) who were reviewed for dignity. The facility failed to provide dignity privacy coverings for urinary catheter drainage bags to two of two residents reviewed (Resident #26 and Resident # 223) reviewed for dignity. This deficient practice could affect residents who require urinary catheters in the facility at risk for diminished quality of life, self- esteem, dignity and increase risk for isolation. The findings included: 1. Record review of Resident # 26's face sheet dated 02/01/23, documented an [AGE] year-old male admitted [DATE], with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), hyperlipidemia (high lipid levels in blood), and essential hypertension (high blood pressure). Record review of Resident # 26's Quarterly MDS dated [DATE], revealed he had a BIMS score of 06, indicating he had severe cognitive impairment. It also indicated he used an indwelling catheter at the time of the assessment. Record review of Resident # 26's Active physician orders dated 02/01/2023 documented: Check Foley Catheter placement every shift .check foley catheter every shift for placement May use leg strap to secure Foley in place .Foley Catheter Care every shift .Foley catheter: Change drainage bag as needed for Leaking. Record review of Resident # 26's comprehensive care plan dated 02/01/23 documented: The resident has an indwelling foley Catheter: 22Fr (French- size of the foley catheter) 30 ML (milliliters) balloon/bulb. Care plan was initiated on 01/12/23 and was revised on 02/01/23. It documented the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door . Check tubing for kinks each shift . monitor and document intake and output as per facility policy . monitor/document for pain/discomfort due to catheter .monitor/record/report to MD for s/sx (signs and symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, Page 1 of 9 675104 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview and observation in Resident #26's room on 01/31/23 at 02:55 p.m. revealed Resident #26 resting in bed, awake and alert conversing with family members at his bedside. Observation also revealed the foley tube hanging off the edge of the bed and the bag laying off left side of bed on the floor exposed without a privacy dignity bag. Interview with the family members at bedside revealed they had observed the urinary drainage catheter bag on the floor exposed since they had arrived. 2. Record review of Resident # 223's face sheet dated 02/01/23, documented a [AGE] year-old male admitted [DATE], with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), hyperlipidemia (high lipid levels in blood), and essential hypertension (high blood pressure). Record review of Resident # 223's Quarterly MDS dated [DATE] revealed he had a BIMS score of 09, indicating his cognitive status was moderately impaired. It also indicated he used an indwelling catheter at the time of the assessment. Record review of Resident # 223's Active physician orders dated 02/01/2023 documented: Check Foley Catheter placement every shift .check foley catheter every shift for placement May use leg strap to secure Foley in place .Foley Catheter Care every shift .Foley catheter Output every shift .Foley catheter: Change drainage bag as needed for leaking . Foley catheter: irrigate foley catheter with NS or H2- as needed for leaking or hematuria . Foley Catheter: Change 18FR (French-size of the foley catheter) 30 ML (milliliters). Balloon as needed for patency, dislodgment and leaking. Record review of Resident # 223's comprehensive care plan dated 02/01/23 documented: The resident has an indwelling Catheter: 18Fr (French- size of the foley catheter) 30 ML (milliliters. Care plan was initiated on 12/20/22. It documented the following interventions: Catheter: last changed: (specify date). Change catheter (frequency) (specify size) (specify type) date initiated 12/20/22 . catheter: the resident has (specify size) (specify type of catheter) Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date initiated 12/20/22 . Check tubing for kinks [# times] each shift. Date initiated: 12/20/22 .Monitor and document intake and output as per facility policy. Date initiated 12/20/22 . Monitor for s/sx (signs and symptoms) of discomfort on urination and frequency . Date initiated 12/20/22 . Monitor/document for pain/discomfort due to catheter. Date initiated 12/20/22. In an observation and interview of Resident # 223 on 1/31/23 at 03:20 p.m. resident was observed resting in bed, awake and alert, and requesting to see his nurse to check on his great toe. Observation was made that resident urinary catheter drainage bag was hanging on side rail of bed and not in privacy bag, In an interview on 01/31/23 at 03:20 p.m. with Resident #223 revealed Resident #223 was unaware the foley drainage bag was not in privacy bag. He was not sure why he had foley catheter or for how long he had it for. In an interview on 02/01/23 at 03:40 p.m. with the DON, revealed the facility did not have policies regarding foley care, indwelling foley care, foley bag care, or catheter care for male or female residents. The DON stated she would provide surveyor C with the skills checklist and their nursing 675104 Page 2 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0550 procedure. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/02/23 at 03:30 p.m. with LVN B, LVN B stated she did observe foley drainage bag was not in privacy bag on both residents under her care (Resident #26 and Resident # 223) during her shift that day. LVN B stated, I did not know they were supposed to be in the room, I knew foley drainage bags were supposed to be in privacy bags in the hallway. LVN B stated that it was the CNA's and the nurse's responsibility to place the foley drainage bag in the privacy bag. LVN B revealed that privacy bags on urinary catheter drainage bags were in fact used for dignity. Residents Affected - Few In an interview with the DON on 02/02/23 at 03:35 p.m. she stated she did observe that Resident #26 and Resident #223 did not have privacy coverings over their urinary catheter drainage bags. The DON stated that after the initial observation on 01/31/23 staff was instructed to provide privacy bags to residents with urinary catheter drainage bags. The DON mentioned that it was the CNA's and the nurse's responsibility to place the foley drainage bag in the privacy bag. The DON noted it was the responsibility of nurses and CNAs caring for the residents to care for the foley drainage bags. The DON acknowledged her responsibility to provide oversight of the care of the resident and for the in-service of the nurses and CNAs and stated she had done so on 1/31/23 after the foley drainage bag for Resident #26 was observed on the floor. She also acknowledged the failure to provide dignity to the Resident by not placing the foley drainage bag in the privacy bag. Record review of a document provided by the facility titled, Catheter Care, Urinary with a revised date 07/15, quoted in part, Place Foley catheter bag in covered pouch. Record review of a document provided by the facility titled, [Facility] RN/LVN Orientation Skills Checklist, signed and dated 08/23/22 by LVN B, urinary foley catheter, insertion/care, and proper positioning-catheter secure to leg were among the skills that were checked off on this date. Facility failed to include covering urinary drainage bag with a privacy bag in the skills checklist listed on this form . Record review of a document provided by the facility titled Clinical Competency Validation Indwelling Urinary Catheter-Insertion of, signed and dated 08/22/22 by LVN B indicated she passed the critical elements necessary to keep the drainage bag below the level of the patient's bladder and off the floor .Secure to bed frame upon orientation. Facility failed to include covering urinary drainage bag with a privacy bag in the critical elements listed on this form. 675104 Page 3 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

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 observation, interview, and record review, the facility failed to ensure that each resident had a right to privacy during medical care for two out of six (Residents #1 and #2) residents observed. Residents Affected - Few LVN #1 failed to ensure privacy for Resident #1 and Resident #2 during wound care. This deficient practice placed residents at risk of loss of privacy and dignity and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 2/2/2023 documented a [AGE] year-old female admitted [DATE] with the diagnoses of: Alzheimer's (progressive mental deterioration), major depressive disorder (depressed mood and long-term loss of pleasure or interest in life), edema (swelling cause by excess fluid trapped in the body), chronic kidney disease (damaged kidneys that cannot filter blood) . Record review of Resident #2's face sheet dated 2/2/2023 documented an [AGE] year-old female admitted [DATE] with the diagnoses of: Alzheimer's (progressive mental deterioration), encounter for palliative care (type of care focused on providing relief from the symptoms and stress of illness), depression (lowering of a person's mood), pain. Observation on 2/1/2023 at 10:00 AM revealed LVN #1 performed wound care for Resident #1. During wound care the resident's roommate was in the room and the door to the room was open to the hall. Curtains were not drawn while wound care was occurring. Observation of 2/1/2023 at 10:20 AM revealed LVN #1 performing wound care for Resident #2. During wound care the resident's roommate was in the room. Curtains were not drawn while wound care was occurring. Resident #2 was not interview able. Interview on 2/2/2023 at 9:40 AM with Resident #1 revealed she stated; sometimes they pull the curtains when they are doing wound care and sometimes they don't. She stated she did not care if they did or not: it did not bother her. Interview on 2/1/2023 at 10:30 AM When questioned about privacy issues with resident #2 LVN #1 said Oh, I was supposed to draw the curtains. During an interview on 2/2/2023 at 9:00 AM, the DON said; I know LVN #1 said the med pass went good. LVN #1 did the wound care yesterday. As far as privacy, you should always pull the curtains. Even if there is another resident or not. Privacy. They have a right to privacy. It could be a dignity issue. You have to do what's right. We do observations on the LVNs. I usually do everyone in a week. We do it randomly. Now that this has happened, we'll do it pretty often. I usually just do pop ins . I don't keep track of it. We do annual check offs. During an interview on 2/2/2023 at 10:00 AM the DON said, I have the policy for privacy and wound care. The privacy policy promotes privacy and dignity. It goes through the rights and explains that we are supposed to maintain resident privacy. The wound care policy also refers to privacy. 675104 Page 4 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0583 Level of Harm - Minimal harm or potential for actual harm Record review of the facility Policy and Procedures for promoting/maintaining resident dignity dated 1/13/23 indicated that all staff members are to maintain resident privacy. Record review of the facility admission agreement revised 10/14/2021 indicates in the statement of resident rights that the resident has the right to privacy. Residents Affected - Few Record review of clinical competency validation for LVN #1 performed during orientation shows critical requirement of providing privacy was met on 9/22/2022. 675104 Page 5 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 by professional standards for food service safety for 1 of 1 kitchen reviewed in that: Residents Affected - Many Hot food on the steam table was below the required temperature for serving The steam table was not clean The shelf on the steam table was not clean A component of the vent hood was not clean There was no cleaning checklist for the kitchen These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. Findings were: Observations of the kitchen during the initial tour with the DM on 01/31/23 at 01:30 PM revealed: the steam table had a thick yellowish crust in each of the 4 compartments. The underside of the shelf above the steam table was coated with a thick brown substance. The vent hood above the stove had thick brown droplets hanging on a pipeline that ran the length of the vent hood, above the stove and the deep fryer. Observations of lunch service food temperatures on 02/01/23 at 11:43 AM by the DM: A digital thermometer was utilized for all foods. The BBQ beef was at 175F, baked beans at 163F, pureed beans at 107F, squash at 157F, fortified soup at 163F, pureed broccoli at 146F. The DM did not immediately remove the pureed beans to reheat. During an interview with DW A and the DM to interpret, as DW A only spoke Spanish, on 01/31/23 at 1:40 PM revealed that DW A cleaned the entire kitchen on Thursdays and Fridays but could not specify what she cleans. The DM stated she asked DW A how she knew what to clean. The DM stated DW A stated to her that the previous manager told her exactly what to clean, she just never got the list. The DM stated DW A was the only one that cleaned everything, and everyone picked up after themselves. During an interview with the DM, RD, and the ADM on 02/02/23 at 09:15 AM the DM stated the baked pureed beans that were temped at 107F yesterday were removed from the steam table and reheated to 156F after this surveyor left the area. The DM could not say why she did not remove the beans immediately. The DM stated hot foods had to be held at 135F. The DM stated the kitchen did not have a cleaning log for staff to follow and initial. The DM stated everyone picked up after themselves. The ADM stated he had been at this facility for about a year. The ADM stated cleaning logs were utilized when the previous DM was employed. The ADM stated the cleaning logs had not been used since the previous DM left. The ADM stated he did not know cleaning lists were not being used by the staff. The ADM stated the DM was responsible for having cleaning logs and that he (ADM) should have followed up on it. The DM stated she had a personal log she signs off, titled, the Daily Kitchen Checklist. The Daily 675104 Page 6 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Kitchen Checklist had 23 items listed on it. The DM stated she checked off the items when she arrived every morning. The DM stated the staff did not know what she was doing with the checklist. The DM stated if there was something she found that had not been done, she would bring it to the staff's attention at that time. The DM stated the staff was supposed to know what to clean, and that sometimes they did not do it. The DM stated the staff was not accountable for the checklist. The DM stated the week she was out with Covid, no one checked. The DM stated the cooks were responsible for cleaning the steam table. The DM stated she placed a maintenance request to have the steam table deep cleaned. The DM stated the shelf above the steam table was part of the steam table, but the staff did not clean it. The DM stated the stuff on the shelf above the steam table could fall into the food or attract gnats. The DM and the ADM stated the maintenance man was supposed to clean the vent hood. The DM stated she put in the maintenance request to have the vent hood cleaned a couple of days ago. The ADM and the DM stated the maintenance man was supposed to clean the vent hood two times a month but had not because he was behind on his work. The ADM stated the maintenance man had been working on other issues. The DM and the ADM stated that what should be happening was scheduling-they needed to keep it (a cleaning schedule) on a daily and monthly basis. The ADM and the DM stated the staff will sign off on the daily checklist. The DM stated it was important so they wouldn't have contaminations, gnats and things falling into food. The DM stated, the residents could get sick-pretty badly. The ADM stated they would be conducting in-services on cleanliness and implementing a plan to make sure the cleaning was being done. The RD stated she did not know the staff was not using a daily checklist. During an interview with the MS on 02/02/23 at 11:32 AM the MS stated he cleaned the filters on the vent hood in between semi-annual contracted cleanings and inspections. The MS stated he did not see the dirty pipeline. The MS stated if the steamer table was cleaned regularly, the scaling would not get like that. The MS stated he was the only one working on everything and it was a lot. During an interview with the COOK on 02/02/23 at 11:40 AM, stated she had been employed at the facility for over 3 years and there was not a cleaning checklist. The COOK stated there was one they used a while ago, but it went away, and she did not know why nor did she ask anyone. The COOK stated the kitchen staff needed a checklist because they forget what to do, get lazy, and just don't do it. The COOK stated the cooks were supposed to be cleaning the steam table. The COOK also stated, I'm not gonna lie- the steam table had not been cleaned since October 2022 which she knew of. A record review of the maintenance schedule for the vent hoods revealed inspections were done on 12/14/22, 06/28/22, and 12/17/22. Scheduled maintenance was performed on 02/09/21, 08/03/21, 02/04/22, and 07/18/22. The record review of the DM's daily kitchen checklists had 23 items to be addressed daily or after each use. The checklists were dated 01/09-01/13/23, 01/16-01/21/23, 01/23-01/27/23, 12/05-12/09/22, 12/12-12/16/22, and 12/19-12/23/22- was all missing checkoffs, and the week of 01/30-02/03/23 was completely missing. Blanks/missing check marks indicated the cleaning task(s) had not been done. There were no checks for any of the weekends. These dates were the only records the DM had. The 23 items included: 1. All dishes, pots, pans and utensils . 2. Freezer, refrigerator and dishwasher temperatures are checked and recorded 3. All sinks .4. All work counters .5. Can opener .6. Steam table is cleaned and sanitized after each use 7. Dishwasher .8. Tray return window .9. Trash can .10. Bathroom .11. Dish cloths are washed .12. Sweep and mop floors daily 13. Open spills are cleaned and ovens turned off 14.wear hair restraints and clean clothing .keep hands cleaned .15. ice machine 16. All tools 17. Clean Steamer and steam table after each use 18. Mixer 19. Receiving dock 20. Slicer .21. Foods thawed properly 22. Foods cooled properly 23. Chemicals stored away from food. 675104 Page 7 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #26) reviewed for infection control, in that Resident # 26 presented with his urinary catheter collection bag on the floor Residents Affected - Few This deficient practice could affect residents with urinary catheters by placing them at risk for urinary tract infections. The findings included: Record review of Resident # 26's face sheet dated 02/01/23, documented an [AGE] year-old male admitted [DATE], with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), hyperlipidemia (high lipid levels in blood), and essential hypertension (high blood pressure). Record review of Resident # 26's Quarterly MDS dated [DATE], revealed he had a BIMS score of 06, indicating he had severe cognitive impairment. It also indicated he used an indwelling catheter at the time of the assessment. Record review of Resident # 26's Active physician orders dated 02/01/2023 documented: Check Foley Catheter placement every shift .check foley catheter every shift for placement May use leg strap to secure Foley in place .Foley Catheter Care every shift .Foley catheter: Change drainage bag as needed for Leaking. Record review of Resident # 26's comprehensive care plan dated 02/01/23 documented: The resident has an indwelling foley Catheter: 22Fr (French- size of the foley catheter) 30 ML (milliliters) balloon/bulb. Care plan was initiated on 01/12/23 and was revised on 02/01/23. It documented the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door . Check tubing for kinks each shift . monitor and document intake and output as per facility policy . monitor/document for pain/discomfort due to catheter .monitor/record/report to MD for s/sx (signs and symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview and observation in Resident #26's room on 01/31/23 at 02:55 p.m. revealed Resident #26 resting in bed, awake and alert conversing with family members at his bedside. Observation also revealed the foley tube hanging off the edge of the bed and bag laying off left side of bed on the floor. Interview with Resident #26's family members at bedside revealed they did not know how long the bag had been laying on the floor or how it got there. They stated they had been visiting Resident #26 for a while now and it had been laying on the floor since they arrived. They also stated they knew it was not supposed to be on the floor but they did not call staff members to come and check on foley bag. In an interview and observation in Resident #26's room on 01/31/23 at 03:45 p.m. of Resident # 26 with the DON, the DON stated she did not know who placed the foley bag on the floor or how it got 675104 Page 8 of 9 675104 02/03/2023 Live Oak Nursing and Rehabilitation Center 2951 Hwy 281 George West, TX 78022

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there. The DON stated she would have to clarify with the nurse because physical therapy had been working with the resident earlier and family members were present at resident bedside earlier. Resident # 26 at that time was asleep and the DON did not ask the resident questions. The DON also mentioned that CNAs and nurses were responsible for caring for foley bags and catheter care. The DON indicated that risk for infection to the resident was the main consequence of foley bags on the floor. The DON also stated that she was responsible for educating and for providing in-services to nurses and CNAs In an interview on 02/01/23 at 03:40 p.m. with the DON, revealed the facility did not have policies regarding foley care, indwelling foley care, foley bag care, or catheter care for male or female residents. The DON stated she would provide surveyor C with the skills checklist and their nursing procedure. In an interview on 02/02/23 at 03:30 p.m. with LVN B, she stated she did not know who placed the foley bag on the floor. LVN B stated she knows there is a risk for contamination and urine can get on the floor if there is trauma to the foley bag. She stated Resident #26 had family members in the room for a while and was unsure if they placed the foley bag on the floor. LVN B stated that it is the CNA's and the nurse's responsibility to care for the foley bag. In an interview with the DON on 02/02/23 at 03:35 p.m. she stated it was the responsibility of nurses and CNAs caring for the residents to care for the foley bags. The DON acknowledged her responsibility to provide oversight of the care of the resident and for the in-service of the nurses and CNAs and stated she had done so on 1/31/23 after the foley bag for Resident #26 was observed on the floor. She also acknowledged the risk for infection to the resident. Record review of a document provided by the facility titled, Catheter Care, Urinary with a revised date 07/15, quoted in part, The purpose of this procedure is to prevent infection of the resident's urinary tract .review the resident's care plan to assess for any special needs of the resident .Be sure the catheter tubing and drainage bag are kept off the floor .Be sure the catheter tubing and drainage bag are kept off the floor . Check drainage tubing and bag to insure that the catheter is draining properly .Secure catheter tubing to prevent pulling .Place Foley catheter bag in covered pouch. Record review of a document provided by the facility titled, [Facility] RN/LVN Orientation Skills Checklist, signed and dated 08/23/22 by LVN B, urinary foley catheter, insertion/care, and proper positioning-catheter secure to leg were among the skills that were checked off on this date. Record review of a document provided by the facility titled Clinical Competency Validation Indwelling Urinary Catheter-Insertion of, signed and dated 08/22/22 by LVN B indicated she passed the critical elements necessary to keep the drainage bag below the level of the patient's bladder and off the floor .Secure to bed frame upon orientation. Record review of Lippincott procedures, Indwelling urinary catheter (Foley) care and management revised 11/27/22, Lippincott procedures - Indwelling urinary catheter (Foley) care and management (lww.com), quoted in part, Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI (catheter associated urinary tract infection) . However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI. 675104 Page 9 of 9