Health inspection·April 26, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4 of 12 resident rooms reviewed on Hall 5 (Room #'s 502, 204, 507, and 510) for resident rights and privacy. The facility failed to ensure Laundry Aide O, HA P, CNA Q and MA R knocked on Room #'s 502, 504, 507, and 510. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: Record review of an in-service, dated 04/21/2023, addressed knocking prior to entering a resident's room revealed Laundry Aide O, HA P, and MA R had signed the in-service. During an observation and interview on 04/24/2023 at 9:15 AM, MA R knocked on open doorframe and immediately entered room [ROOM NUMBER], interrupting conversation with state surveyor. MA R stood at medication cart in front of room [ROOM NUMBER]'s open door and proceeded to prepare the medication. Resident #50 stated he was used to the staff not knocking. During an observation and interview on 04/23/2023 at 9:21 AM, CNA Q entered room [ROOM NUMBER] without knocking, interrupting conversation with state surveyor. CNA Q walked over to the B bed, spoke with Resident #18, and then exited room. Resident #22 (A bed) stated the staff hardly knocked before coming in the room. Resident #22 stated it happened more often with the agency staff. During an observation and interview on 04/23/2023 at 9:34 AM, HA P knocked and immediately entered room [ROOM NUMBER], interrupting conversation with surveyor. Resident #63 immediately stopped talking while HA P took her water pitcher, filled it up, and brought it back. Resident #63 stated she was used to the staff just walking in. During an observation and interview on 04/23/2023 at 9:48 AM, Laundry Aide O opened and entered room [ROOM NUMBER] without knocking, interrupting conversation with surveyor. Resident #54 immediately stopped talking, while Laundry Aide O opened her closet door. Resident #54 stated staff walked in without knocking frequently. Page 1 of 22 675181 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0550 Level of Harm - Minimal harm or potential for actual harm During a confidential telephone interview on 04/25/2023 at 9:23 AM, the family member stated respect and dignity for the residents was her only issue. The family member stated on numerous occasions the staff had left the door open while providing care. The family member also said staff hardly knocked when entering the residents' rooms. The family member stated it was sad to watch the facility staff provide no respect or dignity for the residents at the facility. Residents Affected - Some During an interview on 04/26/2023 at 2:46 PM, a telephone interview was attempted with HA P to gather more information. HA P did not answer the phone and voice message was unable to have been left related to a full mailbox. During an interview on 04/26/2023 at 2:48 PM, a telephone interview was attempted with MA R to gather more information. MA R did not answer the phone and voice message was unable to have been left. During an interview on 04/26/2023 at 2:50 PM, CNA Q stated she remembered entering room [ROOM NUMBER] without knocking. CNA Q stated she should have knocked but the door was opened, and she did not realize the state surveyor was in the room. CNA Q stated it was important to knock and wait for a response to respect the resident and their privacy. During an interview on 04/26/2023 at 2:53 PM, Laundry Aide O stated she remembered entering room [ROOM NUMBER] without knocking. Laundry Aide O stated she should have knocked but another resident had asked for a shirt, and she was trying to find it. Laundry Aide O stated she was busier than normal and was in a hurry and did not remember to knock. Laundry Aide O stated it was important to knock and wait for a response to respect the resident and their privacy. During an interview on 04/26/2023 at 3:03 PM, CNA S stated facility staff should knock and wait for a response prior to entering a resident's room. CNA S stated it was important to knock to maintain the resident's dignity and privacy. During an interview on 04/26/203 at 4:03 PM, the DON stated she expected the facility staff to knock and wait for a response prior to entering a resident's room. The DON stated this was monitored by observations and education was provided to the staff member responsible. The DON stated it was important to knock to maintain resident's dignity and privacy. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated she expected facility staff to knock and wait for a response prior to entering a resident's room. The Administrator stated this was monitored by in-servicing staff and random checks. The Administrator stated it was important to knock prior to entering a resident's room out of respect for privacy and dignity. Record review of the Dignity policy, revised February 2021, revealed 7. Staff are expected to knock and request permission before entering residents' rooms. 675181 Page 2 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #17) reviewed for Medicare/Medicaid coverage. Residents Affected - Few The facility failed to ensure Resident #17 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #17's face sheet, dated 04/25/2023, indicated Resident #17 was an [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included pain in left shoulder, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood). Record review of Resident #17's quarterly MDS assessment, dated 03/02/2023, indicated Resident #17 usually understood others and usually made himself understood. The assessment indicated Resident #17 was moderately cognitively impaired with a BIMS score of 10. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #17 was receiving Medicare Part A services starting on 02/13/2023 and the last covered day of Part A services was 03/14/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #17 of the option to continue services at the risk of out-of-pocket cost. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated she was responsible for ensuring Resident #17 was issued the form. The Administrator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The Administrator stated she was under the impression a SNF ABN form was only needed when a resident had a Part B cap or for services that the MD ordered that Medicare might not pay for. The Administrator stated there was no negative outcome for Resident #17 not receiving a SNF ABN form prior to covered days being exhausted. The Administrator stated the facility did not have a policy concerning notification of ending Part A Benefits or ABN/NOMNC letters. Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed . 675181 Page 3 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete annual comprehensive MDS assessment was transmitted to the CMS System within 14 days after completion for 1 of 22 residents (Resident #19) reviewed for MDS assessments. Residents Affected - Few The facility did not ensure Resident #19's annual comprehensive MDS assessment was transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. The findings included: Record review of Resident #19's face sheet, dated 04/26/2023, revealed Resident #19 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #19's annual comprehensive MDS assessment, dated 03/21/2023, revealed the MDS assessment was completed on 04/05/2023 (V0200C2), which indicated the assessment was transmitted 5 days late. Record review of the MDS 3.0 NH Final Validation Report, completed on 04/24/2023, revealed on page 7 for Resident #19 Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessments (A0310A equals 01, 03, 04, or 05). During an interview on 04/26/2023 at 4:03 PM, the DON stated she was responsible for transmitting the MDS assessments. The DON stated Resident #19's assessment was transmitted late because there was a glitch in the system showing the transmission date for 04/25/2023. The DON stated once the MDS assessment was transmitted the date of transmission was updated to 04/19/2023, making the assessment late. The DON stated the facility staff went by the date in the system and did not calculate the transmission date themselves. The DON stated there was no system in place to monitor for late MDS transmissions because they rarely happened. The DON stated it was important to ensure MDS assessments were transmitted timely was because it was required. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated she expected MDS assessments to be transmitted on time. The Administrator stated it was important to ensure MDS assessments were transmitted timely to stay within regulation. Record review of the Electronic Transmission of the MDS policy, revised in September 2010, revealed 5. MDS electronic submission shall be conducted in accordance with current OBRA regulations governing the transmission of such data. Record review of the MDS Completion and Submission Timeframes policy, revised in July 2017, revealed 2. Timeframes for completion and submission of assessments is based on the current requirements published in the RAI manual. 675181 Page 4 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0640 Level of Harm - Minimal harm or potential for actual harm Review of the CMS RAI Version 3.0 Manual, dated October 2019, revealed in Chapter 5, page 5-3 Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Residents Affected - Few 675181 Page 5 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 22 residents (Resident #2 and Resident #42) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately reflect Resident #2's PASRR Evaluation on the MDS assessment. The facility failed to accurately reflect Resident #42's weight on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 04/25/2023, indicated Resident #2 was a 58-year- old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia, oropharyngeal (difficulty swallowing), personal history of traumatic brain injury (an injury to the brain that damages it and affects how it works), and hemiplegia, unspecified affecting right dominant side (weakness to right side of the body). Record review of the Comprehensive MDS assessment dated [DATE], indicated in Section A1500 Resident #2 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #2 understood others and sometimes was able to make self-understood. The MDS assessment indicated Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #2 required extensive assist with bed mobility, dressing, toilet use, and total dependence for eating personal hygiene and transfers. The MDS assessment indicated Resident #2 required partial/moderate assistance to roll left and right, move from sitting to lying, move from lying to sitting on the side of the bed, chair/bed-to-chair transfer, and toilet transfer. Record review of an undated care plan indicated Resident #2 required follow up on the PASRR Level 2 screening. Record review of Resident #2's PASRR Evaluation dated 03/02/2021 indicated he had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22. 2. Record review of a face sheet dated 04/25/2023 indicated Resident #42 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential primary hypertension (high blood pressure), and unspecified dementia, unspecified severity, without behaviors, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #42 understood others and was able to make self-understood. The MDS assessment indicated Resident #42 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #42 was dependent for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS assessment indicated Resident #42's weight was 110. 675181 Page 6 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the care plan with a problem onset date of 09/02/2020 indicated Resident #42 had a potential for weight loss to weigh and record per physician's orders. Record review of Resident #42's weights indicated her weight on 02/02/2023 was 144 lbs. During an interview on 04/26/2023 at 1:25 PM, the MDS Coordinator stated she was responsible for completing the MDS assessments, and the DON monitored her to ensure the MDS assessments were accurate. The MDS Coordinator stated the DON monitored the assessments for accuracy by reviewing 1-2 MDS assessments weekly. The MDS Coordinator stated Resident #42's weight was incorrect due to a typo. The MDS Coordinator stated she must have typed it in incorrectly and not realized it. The MDS Coordinator stated for Resident #2 she should have answered yes in Section A1500 indicating that Resident #2 was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS Coordinator stated when she completed Resident #2's MDS assessment it was her very first week and that section of the MDS was pre-filled and she had not changed the responses. The MDS Coordinator stated she was trained on completing MDS assessments by the previous MDS nurse, and that the DON notified her when MDS webinars were available, and they both watched them. The MDS Coordinator stated it was important to complete the MDS assessments accurately to show the best assessment of the resident at the time the assessment was completed. The MDS Coordinator stated completing the MDS assessments inaccurately did not affect the residents. During an interview on 04/26/2023 at 2:34 PM, the DON stated the MDS coordinator was responsible for the MDS assessments. The DON stated her expectations were that the MDS Coordinator was accurately completing them. The DON stated she signed the MDS assessments completed, but she did not have the time to review every MDS assessment. The DON stated she randomly performed audits on the MDS assessments to check them for accuracy, and if the MDS Coordinator had any questions regarding the MDS assessments they discussed how to complete them to ensure accuracy. The DON stated Resident #42's weight on the MDS assessment was incorrect and that it was a typo. The DON stated for Resident #2 there was a coding error that he should have been coded as being considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The DON stated it was important to complete the MDS assessments accurately to reflect the actual condition of the resident. The DON stated not completing the MDS assessments accurately affected the claim and payment of services, and they wanted the claim to be accurate. During an interview on 04/26/2023 at 5:15 PM, the Administrator stated the MDS Coordinator, and the DON were responsible for completing the MDS assessments. The Administrator stated she expected them to complete them accurately. The Administrator stated it was important to complete the MDS assessments accurately to correctly report to CMS the care the residents were receiving. The facility's policy on, Electronic Transmission of the MDS revised 09/2010 indicated the MDS coordinator was responsible for ensuring that appropriate edits are made prior to transmitting MDS data and staff members are trained on updates/revisions to the MDS form and software upgrades as they are released. 675181 Page 7 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 22 residents reviewed for care plans. (Resident #2 and Resident #17) The facility failed to care plan that Resident #2 and Resident #17 were PASRR positive. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. The findings included: 1. Record review of a face sheet dated 04/25/2023, indicated Resident #2 was a 58-year- old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia, oropharyngeal (difficulty swallowing), personal history of traumatic brain injury (an injury to the brain that damages it and affects how it works), and hemiplegia, unspecified affecting right dominant side (weakness to right side of the body). Record review of the Comprehensive MDS assessment dated [DATE], indicated in Section A1500 Resident #2 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #2 understood others and sometimes was able to make self-understood. The MDS assessment indicated Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #2 required extensive assist with bed mobility, dressing, toilet use, and total dependence for eating personal hygiene and transfers. Record review of Resident #2's PASRR Evaluation dated 03/02/2021 indicated he had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22. Record review of an undated care plan indicated Resident #2 required follow up on the PASRR Level 2 screening. Resident #2's care plan did not indicate he had a developmental disability, which made him PASRR positive. 2. Record review of a face sheet dated 04/25/2023 indicated Resident #17 was an [AGE] year old female readmitted to the facility on [DATE] with diagnoses which included cerebral palsy (disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and schizoaffective disorder, bipolar type (a condition that can make you feel detached from reality and can affect our mood). Record review of Resident #17's Comprehensive MDS assessment dated [DATE] indicated in Section A1500 Resident #17 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #17 understood others and was able to make self-understood. The MDS assessment indicated Resident #17 had a BIMS score of 8, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing and personal 675181 Page 8 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0656 hygiene, and was dependent for toilet use and required supervision for eating. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #17's PASRR Evaluation dated 07/01/2022 indicated she had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22. Residents Affected - Few Record review of Resident #17's care plan with a problem onset date of 06/15/2022 indicated Resident #17 required follow up on the PASRR Level 2 Screening. Resident #17's care plan did not indicate she had a developmental disability, which made her PASRR positive. During an interview on 04/26/2023 at 1:47 PM, the MDS Coordinator stated the Social Worker was responsible for care planning the residents PASRR status. The MDS Coordinator stated the ADON was responsible for overseeing the care plans. The MDS Coordinator stated if a resident was PASRR positive it should be part of the care plan, and it was important to include it so the staff could meet the resident's needs. During an interview on 04/26/2023 at 1:50 PM, the ADON stated the IDT was responsible for completing the care plans. The ADON stated she put the care plans in the electronic health record and the DON looked over them to ensure they included everything necessary for the resident's care. The ADON stated for Resident #2 and Resident # 17 she had put in the statement that they required follow up on the PASRR Level 2 Screening because this is what was put in for all the residents that were PASRR positive. The ADON stated she did not put in the care plan what qualified the resident to receive PASRR services or specific services recommended by PASRR. The ADON stated the care plans should be individualized and person centered. The ADON stated it was important for the care plans to be individualized and person centered so the staff would know how to take care of the residents. During an interview on 04/26/2023 at 2:00 PM, the Social Worker stated the IDT completed the care plans and the DON reviewed them. The Social Worker stated she had never been told the care plan should include that the residents were PASRR positive, and the services recommended by PASRR. The Social Worker stated the statement that the resident required follow up on the PASRR Level 2 Screening was used on all the residents that were PASRR positive. The Social Worker stated she did not know if using the same statement for all the residents was individualized and person centered. The Social Worker stated she did not know how not including the residents PASRR positive status and services recommended could affect the residents. During an interview on 04/26/2023 at 2:59 PM, the DON stated the IDT was responsible for completing the care plans, but she reviewed them to ensure they were complete. The DON stated the statement, in the care plan, the resident required follow up on the PASRR Level 2 Screening was used for all the PASRR positive residents. The DON stated they did not include in the care plan that the resident was PASRR positive, and they did not individualize the approach to indicate what qualified the resident for PASRR services or what recommendations for services were made. The DON stated it was important for the care plan to be individualized and person-centered for all the residents because it gave an outline of how to care for the resident. During an interview on 04/26/2023 at 5:19 PM, the Administrator stated the IDT team was responsible for ensuring the care plans were individualized and person-centered. The Administrator stated the DON reviewed the care plans. The Administrator stated she expected the care plans to be person centered and individualized. The Administrator stated the residents PASRR positive status, and any recommendations made by PASRR should be included in the care plan. The Administrator stated the resident not having a person centered and individualized care plan would not be about the care they need. 675181 Page 9 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and implemented for each resident . Residents Affected - Few 675181 Page 10 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident # 56) reviewed for dialysis. Residents Affected - Few 1.The facility failed to have a physician's order for dialysis for Resident #56. 2.The facility failed to ensure nursing staff monitored Resident #56's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection. 3. The facility failed to develop a person-centered care plan for Resident #56's dialysis treatments and care. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings include: Record review of Resident #56's face sheet dated 04/25/23, indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #56 had a diagnoses of type 2 diabetes (blood sugar disorder), cerebral infarction (lack of adequate blood supply to the brain cells) and stage 5 end stage renal disease (kidney failure). Record review of Resident #56's MDS dated [DATE], indicated he had a BIMS score of 15 suggesting cognitively intact. The MDS indicated Resident #56 had the ability to understand others and made himself understood. The MDS indicated Resident #56 had a diagnoses of End stage renal disease and dependence on renal dialysis. Record review of Resident #56's care plan last updated on 04/06/2023 did not reveal Resident #56 was receiving dialysis, the venous catheter was being monitored by the nurses for signs and symptoms of infection, or auscultation/palpation of the AV fistula (pulse, bruit and thrill) was being done to assure adequate flood flow or monitoring of complications. Record review of the physician orders dated 04/2023 indicated Resident #56 had End stage renal disease. Resident #56's orders indicated to give midodrine 10mg by mouth every Monday, Wednesday and Friday before dialysis. Resident #56's physician orders indicated to monitor the left AC for signs and symptoms of infection daily and keep the site clean and dry. No order was indicated for dialysis. During an interview on 04/26/23 at 10:42 AM, Resident #56 stated he went to dialysis on Monday, Wednesday, and Friday. Resident #56 stated the nursing facility monitored his AC site and staff monitored for a bruit and thrill at the dialysis center and the nursing facility. During an interview on 04/25/23 at 4:25 PM, LVN B stated she did not know staff had to write an order for dialysis when residents were admitted to the facility. LVN B stated the process for dialysis 675181 Page 11 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents upon admission to the facility was to receive report from the hospital and then the nurses would have added it to the 24-hour report. LVN B stated the facility only used one dialysis center and she checked Resident #56's dialysis site 3 times a week before sending him to dialysis. LVN B stated she had charted Resident #56 had a positive thrill and bruit when he was on skilled services in the nurse's notes, but she did not chart it anywhere now because he was no longer on skilled services. LVN B stated residents that received dialysis should be care planned, but either way she made sure Resident #56's site was looked at. LVN B stated not checking the bruit and thrill could have resulted in the resident being dialyzed and residents should have been checked for a bruit and thrill before they were sent to the dialysis center so they could have informed the dialysis center ahead of time to make other arrangements if needed. LVN B stated if Resident #56's AC site was not monitored, then the site could have clotted, or the resident could have been hospitalized due to an infection. LVN B stated the importance of having a dialysis order was so everyone was notified the resident was on dialysis. During an interview on 04/26/23 at 9:37 AM, the DON stated the charge nurses were responsible for adding an order for dialysis when residents were admitted to the facility. The DON stated a 2nd nurse double checked all the physician orders and then she was responsible for signing off on them. The DON stated, she did not go line by line when she checked the orders since a 2nd nurse had already checked them. The DON stated there was not a certain nurse that was designated to checking the physician orders as long as it was a 2nd nurse. The DON stated the IDT team was responsible for reviewing care plans quarterly and she was responsible for signing off on the care plans. The DON stated she expected the nurses to have checked Resident #56's AC site daily for infection and it should have been care planned because care plans address resident needs. The DON stated there was no harm in not care planning on a resident that received dialysis because the nurses were familiar with their residents, and it would have been indicated on the 24-hour report. During an interview on 04/26/23 at 5:30 PM, the Administrator stated she was not familiar on how the nurses documented on dialysis residents. The Administrator stated she expected the nurses to complete a person-centered care plan on dialysis residents and documentation to be done accurately. The facility's policy on, End-Stage Renal Disease, Care of a Resident with revised on 09/2010 indicated .agreements between this facility and the contracted ESRD facility included all aspects of how the residents care would be managed: how the care plan would be developed and implemented, and how information would be exchanged between the facilities. The residents comprehensive care plan would reflect the residents needs related to ESRD/dialysis care. 675181 Page 12 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Residents Affected - Some The facility failed to provide RN coverage for 8 consecutive hours daily on 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings include: Record review of a nursing staff information sheet dated 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022 indicated that the facility did not have an RN in the facility. During an interview on 04/26/2023 at 9:15 a.m., the DON stated she was aware that there was a regulation to have 8 hours of RN coverage a day. The DON stated she was aware that there were days RNs were not scheduled due to no RN available. The DON stated she did have an ad running for a registered nurse. When asked how often days with no RN onsite, the DON stated currently about 4 days a month. The DON stated she was always available by phone if no RN was on schedule to work, and she lived 7 minutes from the facility. When asked how the facility provided care to residents that required a RN if one was not available to work, the DON stated she would come in to take care of the need. The DON stated she was unaware of a resident who needed care or services only performed by a RN and did not receive it. When asked possible negative outcomes to residents if no RN was on duty, she stated she did not think there would be one since she was on call and available and could be at the building quickly. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated the DON was responsible for ensuring a registered nurse was in the building 8 hours every day. When asked possible negative outcomes to residents if no RN was on duty, she stated she did not think there was one since the DON was always available by phone. The Administrator stated there was not a policy and procedure regarding RN staffing. 675181 Page 13 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 3 medication carts (nurse cart 5/6) reviewed for controlled medications. The facility did not ensure LVN's B, E, F, G, H, K, L, M, N counted controlled drugs every shift change. This deficient practice could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: During a record review and random count observation of nurse cart 5/6 with LVN B revealed missing signatures for Off duty and On duty for 4/9/2023, 4/10/2023, 4/11/2023, 4/14/2023, 4/18/2023, 4/19/2023, 4/20/23, 4/21/2023, 4/22/2023, 4/23/2023, 4/24/2023, and 4/25/2023 of the narcotic count sheet. Record review of a facility in-service dated 03/21/2023 titled Medication Destruction indicated LVN B, LVN E, RN F, and LVN G were in serviced on counting controlled drugs every shift change. During an interview on 4/26/2023 at 10:28 a.m., LVN E stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/9/2023. LVN E stated, I forgot to sign. LVN E stated this failure could potentially cause a drug diversion. An attempted telephone interview on 4/26/2023 at 10:34 a.m. with RN F, was unsuccessful. During a telephone interview on 4/26/2023 at 10:41 a.m., LVN H stated she should have signed the narcotic count log after counting the controlled drugs with the nurse after her shift on 4/9/2023. LVN H stated she forgot to sign. LVN H stated this failure could potentially cause a drug diversion. An attempted telephone interview on 4/26/2023 at 10:48 a.m. with LVN M, was unsuccessful. An attempted telephone interview on 4/26/2023 at 10:51 a.m. with LVN K, was unsuccessful. During a telephone interview on 4/26/2023 at 12:47 p.m., LVN N stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/22/2023 and 4/23/2023. LVN N stated, I forgot. LVN N stated this failure could potentially cause a drug diversion. During a telephone interview on 4/26/2023 at 1:00 p.m., LVN L stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/18/2023, 4/19/2023, and 4/18/2023. LVN L stated this failure could potentially cause a drug diversion. During a telephone interview on 4/26/2023 at 1:09 p.m., LVN B stated she should have signed the 675181 Page 14 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/10/2023, 4/11/2023, 4/14/2023, 4/19/2023, 4/20/2023, and 4/24/2023. LVN B stated, I don't know why it was overlooked. LVN B stated this failure could potentially cause a drug diversion. During an interview on 4/26/2023 at 10:53 a.m., LVN G stated she was responsible for counting and signing the narcotic count sheet with the on duty nurse at the end of her shift on 4/21/2023. LVN G stated, honestly I forgot. LVN G stated this failure could potentially cause a drug diversion. During an interview on 4/26/2023 at 9:15 a.m., the DON stated she expected nurses to signed at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated nurses were trained upon hire and as needed in serving. The DON stated her and the ADON were responsible for randomly checking the narcotic count sheets for accuracy in documentation. The DON stated the last audit was done on 4/7/2023 with the pharmacy consultant. The DON stated a couple of signatures were missing on the narcotic sheet for March and April. The DON stated nurses not ensuring narcotic count sheets were signed at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse could result in drug diversion. During an interview on 4/26/2023 at 4:49 p.m., the Administrator stated she expected narcotic sheets to be signed at the beginning and end of their shift after they completed count with the incoming and off-going nurse. The Administrator stated this failure could result in drug diversion. Record review of the undated facility's policy titled, Controlled Drug Policy and Procedure indicated, . 1. To provide physical facilities and method of operation for the administration and control of narcotics, which will meet the requirements of State and Federal narcotic enforcement agencies 2. To ensure maximum safety for patients and nursing personnel . Narcotic Count and Inventory . 1. Controlled drugs were counted every shift by the nurse and/or MA coming on duty with the nurse and/or MA going off duty . 675181 Page 15 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents reviewed for unnecessary psychotropic medications. (Resident's #9 and #31) The facility failed to ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #9 and #31. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. The findings included: 1. Record review of Resident #9's face sheet, dated 04/26/2023, revealed Resident #9 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life events). Record review of the physician orders, dated April 2023, revealed Resident #9 had an order, which started on 11/22/2022, for clonazepam (anti-anxiety) 1mg by mouth three times daily. Record review of the MAR, dated April 2023, revealed Resident #9 received clonazepam 1 mg. Record review of the MDS assessment, dated 03/16/2023, revealed Resident #9 had clear speech and was understood by staff. The MDS revealed Resident #9 was able to understand others. The MDS revealed Resident #9 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed Resident #9 had a PHQ-9 score of 04, which indicated normal or minimal depression. The MDS revealed Resident #9 had no behaviors or rejection of care. The MDS revealed Resident #9 received an anti-anxiety and anti-depressant medication 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, dated 02/12/2023, revealed Resident #9 no longer exhibited physical combative behavior but did have verbally abuse behaviors. The interventions included: Administer behavior medication as ordered by physician. The care plan further revealed Resident #9 had potential for drug toxicity due to her medication regimen. Record review of the pharmacy recommendation, dated 01/09/2023, revealed Resident #9 was receiving clonazepam 1mg three times a day and it was due for review. The pharmacy recommendation further revealed a trial dosage reduction was recommended to decrease clonazepam to 0.5mg three times daily. No indication or rationale was provided for continued use. During an observation and interview on 04/24/2023 at 9:33 AM, Resident #9 was sitting up in her wheelchair. Resident #9 was wringing and constantly moving her hands. Resident #9 stated she was upset 675181 Page 16 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some about some medications that were removed from her room. Resident #9 stated her medication regimen was sorta helping and she did not believe she was having side effects from the medications. 2. Record review of Resident #31's face sheet dated 04/26/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement and often includes tremors), adjustment disorder with mixed anxiety and depressed mood (feeling unmotivated, irritable and difficulty with concentrating) and chronic kidney disease (disease of the kidneys leading to renal failure). Record review of Resident #31's MDS dated [DATE] indicated a BIMS score of 8 indicating mildly impaired. The MDS indicated Resident #31 was understood and was able to understand others. The MDS indicated Resident #31 felt down or hopeless on 2-6 days and little interest in doing things on 7-11 days over the last 2 weeks. The MDS indicated Resident #31 had diagnoses of anxiety and depression. Record review of the care plan dated 01/21/2021 indicated Resident #31 had socially inappropriate and disruptive behavior that had been observed by staff causing the resident to fall. The goal was to maintain appropriate behavioral functioning by the next evaluation. The interventions included to encourage family to visit and to approach the resident in a warm and positive manner. The care plan indicated Resident #31 had a potential for drug toxicity due to clonazepam to control Parkinson's symptoms. The goal was for Resident #31 to be free of side effects from medications by next evaluation. The interventions included to monitor for side effects and effectiveness of the medication, contact the physician as needed, monitor the resident for tremors and document, observe the resident's gait for steadiness, balance, muscle coordination, and the ability to position and turn. Record review of the physician orders dated 04/2023 indicated Resident #31 was taking clonazepam 0.5mg by mouth twice daily due to Parkinson's. Record review of Resident #31's medication administration record indicated she was taking clonazepam 0.5mg by mouth twice daily for Parkinson's at 8:00 AM and 8:00 PM. Record review of the pharmacy recommendation form dated 03/05/2023 by the consultant pharmacist, indicated the psychoactive medication clonazepam 0.5mg twice a day was due for review, and to evaluate Resident #31 for a trial dosage reduction. The suggested change was to decrease clonazepam 0.5mg to daily. Physician A indicated to continue clonazepam 0.5mg twice daily. No indication or rationale was provided for continued use. During an interview on 04/26/23 at 8:59 AM, the ADON stated the GDRs were done monthly by the pharmacist. The ADON stated she was responsible for completing the GDR's and after she reviewed the report, it was then sent to clinic for the prescribing physician to sign. The ADON stated a staff nurse went to the clinic weekly to pick up documentation from the prescribing physicians. The ADON stated she, was not responsible for Physician A not providing a rational on the pharmacy recommendation form and she could not tell Physician A what to do. The ADON stated, if the resident was already on the medication and they were looking at reducing it, then she did not think there would be any consequences in not providing a rational, because the resident was being treated and not losing anything. The ADON stated, If they thought something needed to be changed, then they would notify Physician A and he would take care of it. During an interview on 04/26/23 at 9:37 AM, the DON stated the rationales should have been documented either on the pharmacy recommendation form or on a progress note. The DON stated Physician A knew 675181 Page 17 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his patients better than the staff and it could not harm the resident in any way that the rational was not provided. The DON stated staff would have pursued Physician A's recommendation if they thought it needed to be changed. During an interview on 04/26/23 at 1:36 PM, Physician A stated he usually indicates a rational on the pharmacy recommendation form and he usually does what the pharmacist recommends. Physician A stated he must have gotten in a hurry that day and just forgot to write a rational on Resident #31's form. Physician A stated if there was a concern with Resident #31, then the nurse would have added her comments on the form for him to look at or notified him verbally because the nurses were good at notifying him of any changes or recommendations that needed to be done. Physician A indicated the rational was used to communicate why changes in the medication were made. During an interview on 04/26/2023 at 3:54 AM, the ADON stated the system in place for pharmacy recommendations, which included GDRs was placing the pharmacy recommendation in the physician's folder and taking them to the physician's office once time weekly. The ADON stated each week, when a new folder was dropped off, the facility staff would ask if anything was ready to be picked up. The ADON stated the physician's had not been provided education on GDR recommendations and providing a clinical rationale for the continued use of a psychotropic medication. The ADON stated it was important to ensure clinical rationales were provided for continued use of psychotropic medications because it was regulatory. During an interview on 04/26/2023 at 4:03 PM, the DON stated education had not been provided to the physician's regarding documenting clinical rationales for continued use of psychotropic medications. The DON stated GDRs were important because it was regulatory. During an interview on 04/26/23 at 5:30 pm, the Administrator indicated the nurses were responsible for the pharmacy recommendation forms and she expected them to be done accurately. Record review of the facility's policy on, Tapering Medications and Gradual Drug Dose Reduction dated 7/2022 indicated . When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction. 675181 Page 18 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

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 in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: 1. Food items were dated and labeled. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation and interview with the Dietary Manager of the refrigerator and freezer on 04/24/2023 starting at 9:52 a.m., revealed 2 plastic bags that was identified by the Dietary Manager as cheese pizza unlabeled and undated; 1 plastic bag that was identified by the Dietary Manager as corn dogs unlabeled; 1 plastic bag that was identified by the Dietary Manager as hamburger patties unlabeled; 2 bags that was identified by the Dietary Manager as tater tots unlabeled; 3 bags that that was identified by the Dietary Manager as French fries unlabeled; a tray with 10 (16oz) of margarine undated; 1 bag that was identified by the Dietary Manager as tomatoes unlabeled and undated; and 1 bag that was identified by the Dietary Manager as cucumbers unlabeled and undated. 2. During an observation on 04/24/2023 at 10:13 a.m., [NAME] C was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] C's hair was visible outside of the hairnet at the ears and necks. During an interview on 04/26/2023 at 12:25 p.m., Dietary Aide D stated the morning cook and aide were responsible for labeling and dating. Dietary Aide D stated that way staff would know what food and how old it was. Dietary Aide D stated these failures could potentially cause food borne illness/contamination. During an interview on 04/26/2023 at 12:34 p.m., [NAME] C stated whoever worked the morning that the truck comes in was responsible for labeling and dating. [NAME] C stated the hair restrained should cover her whole head. [NAME] C was unable to say why her hair was not covering her whole head. [NAME] C stated these failures could potentially cause food borne illness/contamination. During an interview on 04/26/2023 at 1:11 p.m., the Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager said all food should be labeled with date received and the date it was opened. The Dietary Manager stated when the food truck comes and delivers, whoever touched the item should label and date the item. The Dietary Manager stated when the food was opened it should be labeled and dated. The Dietary Manager stated all hair must be covered while in the kitchen area. The Dietary Manager stated she did daily spot checks during the day and address any issues. The Dietary Manager stated she was under the impression if you can see through the bag, it did not have to be labeled. The Dietary Manager stated these failures could potentially cause a food borne illness or cross contamination. 675181 Page 19 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0812 Level of Harm - Minimal harm or potential for actual harm Record review of the Food Receiving and Storage policy, last revised on 07/2014, indicated food shall be received and stored in a manner that complies with safe food handing practices . 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated . 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens . Residents Affected - Some 675181 Page 20 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 2 of 4 meetings (May 2022, and September 2022) reviewed for QAPI. Residents Affected - Few The facility did not ensure the ADON attended QAPI meetings in May 2022, and September 2022. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for May 2022 and September 2022 indicated the ADON did not sign in for their meetings. Record review of an undated form titled QAA Committee Information indicated the QAA Committee members were the Administrator, MD, Pharmacy Consultant, Social Worker, DON and the ADON. During an interview on 04/26/2023 at 8:45 a.m., the ADON stated she did not attend the meetings, but she did review the minutes with the DON. The ADON stated if she reviewed the minutes after the meetings, she should have signed the sign in sheet. The ADON stated I have no idea why I didn't sign the sign in sheet. The ADON stated she did not feel there was a negative outcome with her not attending the QAPI meetings due to her communicating with the DON. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated per documentation it appeared the ADON did not attend the quarterly QAPI meetings in May 2022, and September 2022. The Administrator stated if she attended the meetings or reviewed the minutes after the meetings, she should have signed the sign in sheet. The Administrator stated she did not feel there was a negative outcome with the ADON not attending the QAPI meetings Record review of the facility's undated Quality Assurance Performance Improvement Program Plan indicated the main purpose for the facility QAPI plan was to take a proactive approach to continually improve the way the facility care for and engage with residents, caregivers, and other partners so that the facility may realize their vision of becoming the community's first choice in skilled nursing care . the Administrator, DON, infection control, MD, consulting pharmacist, the ADON, and other staff as assigned will provide QAPI leadership by being on the QAPI Committee. The ADON will direct the QAPI Committee meetings . 675181 Page 21 of 22 675181 04/26/2023 Carriage House Manor 210 Pipeline Rd Sulphur Springs, TX 75482

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 reviews the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 1 of 1 facility and 1 of 1 staff (Laundry Aide O) reviewed for transportation of linens. Residents Affected - Few The facility failed to ensure Laundry Aide O covered the clean linen cart while passing out resident's personal laundry. This failure could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life. The findings included: During an observation on 04/24/2023 between 9:48 PM - 10:08 PM, Laundry Aide O was passing out clean linen on Hall 2 ([NAME] St.) and Hall 5 (Church St.). The clean linen cart had a small purple blanket that was thrown on the top of the hanging clothes. The clothes were not fully covered and visible from the hallways. During an interview on 04/26/2023 at 2:53 PM, Laundry Aide O stated the clean linen carts should have been adequately covered while she was passing out resident's personal laundry. Laundry Aide O stated the small purple blanket was provided by the facility for use to cover the clean linen carts. Laundry Aide O stated she did not feel the purple blanket was large enough to adequately cover the clean clothes and had reported it to the Housekeeping Supervisor. Laundry Aide O stated it was important to ensure clean clothing was adequately covered during transportation to prevent cross-contamination and infection control. During an interview on 04/26/2023 at 3:36 PM, the Housekeeping Supervisor stated clean linen carts should have been covered during transportation and delivery. The Housekeeping supervisor stated the clean linens should not have been visible. The Housekeeping Supervisor stated she was unaware the purple blanket was too small. The Housekeeping Supervisor stated she monitored this by random checks and training during the hire and orientation process. The Housekeeping Supervisor stated it was important to ensure clean clothing was adequately covered during transportation and delivery to prevent cross contamination. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated clean linen carts should have been covered. The Administrator stated she expected laundry and housekeeping staff to ensure this was completed. The Administrator stated the Housekeeping Supervisor was responsible for ensuring the clean linen carts were adequately covered. The Administrator stated it was important because of infection control. Record review of the Departmental (Environmental Services) - Laundry and Linen policy, revised in January 2014, did not address delivery of clean linens. 675181 Page 22 of 22