Health inspection·June 28, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #199) reviewed for accidents and supervision. The facility failed to ensure there was adequate supervision while Resident #199 was smoking. This failure could place residents at risk for injury due to the lack of supervision provided by the facility. Findings include: Record review of Resident #199's electronic face sheet revealed Resident #199 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #199 had diagnoses which included Dementia, Alzheimer's and Depression. Record review of Resident #199 Comprehensive assessment, dated 06/09/2023, revealed a BIMS of 09, which indicated moderately impaired cognition. Resident #199 was a tobacco user. Record review of Resident #199 Comprehensive Care Plan, dated 06/26/2023, revealed no evidence regarding smoking. Record review of Resident #199 Safe Smoking Assessment, dated 06/07/2023, revealed This Resident requires direct supervision while smoking. During an observation and interview on 06/28/23 at 02:10 PM, Resident #199 was seen outside smoking, unsupervised. Resident #199 stated his family brought him cigarettes and staff light cigarettes for him. During an interview on 06/28/2023 at 2:35 PM, the DON stated residents should not be outside smoking alone. She also stated the facility did not allow any residents to smoke unsupervised. The DON stated her expectations about Resident #199 was to be educated and staff were to make sure cigarettes were put out entirely. She also stated the cigarettes were to be disposed down into the closed container. The DON stated staff were to ensure residents were supervised while smoking. The DON stated it was the housekeeping department's responsibility to observe Resident #199 on 06/28/2023. The DON stated Resident #199 could have burned himself. Page 1 of 8 675319 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0689 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/28/202 at 5:23 PM, the Administrator stated her expectation was Resident #199 would smoke during the smoking times and would not have access to cigarettes. The Administrator stated all staff were responsible to monitor residents while smoking. She stated the resident could have burned himself while smoking unsupervised. The Administrator stated she was not sure how Resident #199 was able to get cigarettes. Residents Affected - Few Record review of the facility provided policy revealed in the Resident admission packet #26 titled, Smoking Policy, revised 11/1/17, MAKE 2, revealed the following: (1) Smoking tobacco, matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. (2) A safe smoking assessment will be done regularly for each resident who smokes. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the resident's limitations with smoking. The resident must be within direct view of the smoking supervisor, in reasonably close proximity of the supervisor. And the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor. Whether staff or visitor must be aware of these responsibilities. 675319 Page 2 of 8 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for one of two medication carts reviewed for medication storage. The facility failed to ensure medication supplies were secured or attended by authorized staff when the medication cart was left unlocked and unattended. This failure could result in access to medications by unauthorized staff or residents leading to possible harm or drug diversion. The findings Included: During an observation on 06/26/23 at 02:09 p.m., a medication cart was observed to be unlocked and unattended outside the nurse's station near Hall 3. Residents were observed passing by the cart. Review of the content of the medication cart revealed the cart contained the following: analgesics (non-narcotic and narcotic pain relievers), antacids (relieve heartburn), antianxiety drugs (have a calming effect and relax muscles), antiarrhythmics (controls irregular heartbeats), antibiotics (for infections), anticoagulants and thrombolytics (prevent blood clots), anticonvulsants (prevent seizures), antidepressants (improve mood), antidiarrheals (relieve diarrhea), antiemetics (relieve nausea and vomiting), antihistamines (control allergic reactions), antihypertensives (control blood pressure), anti-inflammatories (reduce swelling), antipsychotics (treat symptoms of mental illness), antipyretics (lower a fever), barbiturates (help with sleep), beta-blockers (decrease heart rate), cold cures (treat symptoms of a cold), cough suppressant (control coughing), decongestant (decrease nasal stuffiness), diuretics (increase amount of water eliminated), expectorant (help eliminate phlegm), hormones (replace low levels in the body), hypoglycemics - oral (lower the amount of sugar in the blood), laxatives (help with bowel movements), muscle relaxants (reduce muscle spasms), sedatives (have a calming effect and relax muscles), sleeping drugs (promote sleep), vitamins (supplement low vitamin levels in the body). During an interview on 06/26/23 at 2:10 PM LVN-A stated she had left cart and went down Hall 4 to see a resident. LVN-A stated the cart should have been locked when unsupervised. LVN-A stated the effects of an unattended, unlocked medication cart on residents may be a resident could get a medication that was not theirs. A resident taking a medication not prescribed to them could cause dizziness or worse side effects and could have possibly been deadly. During an interview on 06/28/23 at 10:21 PM, the DON stated her expectations were that the carts should be locked if a nurse or medication aide was not standing with cart using it. The staff member responsible for the medication cart should not be down another hall before ensuring the cart is locked. The DON stated the effect an unlocked medication cart could have on residents was a resident could take medication causing ill effects. The DON explained monitoring medication carts was the responsibility of the ADON, DON and ADMN when they were out on halls. The DON stated the failure occurred due to the nurse being nervous that state was in the building and the nurse had just completed count with previous shift. The DON stated an in-service on medication safety was presented last month. During an interview on 06/28/23 at 05:14 PM, the ADMN stated her expectations were for medication 675319 Page 3 of 8 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0761 Level of Harm - Minimal harm or potential for actual harm carts to be locked at all times. She stated monitoring medication cart safety was the responsibility of the nurse assigned to the cart and any department head while walking around facility. The ADMIN stated the effect an unlocked medication cart may have on residents would be if a resident could get medications that do not belong to them, a resident may not have needed medications. The ADMIN stated the failure occurred due to the nurse being nervous and forgot to lock the medication cart. Residents Affected - Few Record review of the in-service training presented 05/06/2023 revealed 8 of 19 nurses on staff attended the in-service. The topic of the in-service was Med Administration. Review of the facility's policy titled Medication Carts, dated 2003, revealed 1. The medication carts shall be maintained y the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse. 3. Carts not in use are to be stored in a designated area not blocking egress in the building. 4. Carts must be secured. 675319 Page 4 of 8 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

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 food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff practiced proper hand hygiene. This deficient practice could place residents at risk for food borne illness and cross-contamination. Findings include: During an observation on 06/26/2023 at 11:20 AM, DA B exited the kitchen without removing gloves. DA B then reentered the kitchen with gloves on hands while holding a bowl of pudding. DA B did not wash her hands or change gloves. DA B then opened the refrigerator with gloved hands, placed the bowl of pudding into the refrigerator. DA B then scratched her head underneath her hair net then rubbed her nose with the same gloved hands. DA B then reached into her pocket with her gloved hand, pulled out a pen, wrote on a label, and placed the label onto another bowl of pudding before placing it into the refrigerator. DA B then grabbed a cup from a rack with the same gloved hands then exited the kitchen. DA B then returned to the kitchen with gloves still on, holding a cup of tea and did not wash hands. DA B then reached into her pocket again with gloved hand, pulled out a pen, wrote on a label, and placed it on the cup of tea. DA B then rubbed her nose again with her gloved hand. DA B then exited the kitchen again with gloves still in place. DA B then returned to the kitchen with gloves still on and did not wash her hands. DA B again reached into her pocket with gloved hands, pulled out her cell phone, touched the screen, then placed the cell phone back into her pocket with her gloved hand. DA B, with the same gloved hands, removed the coffee filter from the coffee machine, removed the lid from the trash can, dumped the coffee grounds into the trash can, replaced the lid on the trash can, rinsed out the coffee filter in the sink, and returned the coffee filter to the coffee maker. DA B did not wash her hands. DA B, with the same gloved hands, then grabbed a sanitation cloth from bucket and wiped down the coffee maker, cabinet, and serving cabinet. DA B then exited the kitchen with gloves still on hands. DA B reentered the kitchen with a bucket of ice and placed in on the serving cabinet with the same gloved hands. DA B then washed her hands for less than 5 seconds, with soap and water, and turned off the faucet with her bare hands, grabbed a paper towel, dried hands, and placed paper towel on the serving cabinet. DA B then reached into her pocket, answered her phone, then placed the cell phone back into her pocket. DA B, without gloves on hands, then grabbed a glass, dipped it into the ice bucket, scooped up ice, then used her bare hand to guide the ice into the cup. DA B did this for 15 cups. DA B reached into her pocket, pulled out her phone, then placed it back in her pocket. DA B began placing napkins, silverware, pears, and butter packets on each tray and placed them on the serving cart. DA B knocked a bucket which contained plastic butter packets on to the floor, which caused many butter packets to fall out onto the floor. DA B kneeled to the floor and picked up the butter packets and placed them on the handwashing sink. DA B then placed the bucket of butter packets from the floor on the serving table next to the resident's meal trays. DA B washed her hands for less than 5 seconds, with soap and water, turned off the faucet with her bare hands, dried her hands with a paper towel, then placed the paper towel on the serving cabinet. DA B continued to place napkins, silverware, pears, and butter on the trays. During an attempt to interview on 06/26/2023 at 2:00 PM DA B was not available in person of via 675319 Page 5 of 8 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0812 phone call. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/26/2023 at 02:15 PM, DM A stated staff must wash hands every time staff entered the kitchen. She stated once in the kitchen there was no need to wash any more until you exited. She stated gloves should be worn anytime food was being handled or served. She stated if something dirty was touched while wearing gloves, new gloves should be donned. DM A stated staff should not handle personal items while serving food or with gloves on. She stated DA B should have changed gloves and washed her hands after she touched her phone. DM A stated she was responsible for training the dietary staff. She stated she in-serviced DA B after observation because she noticed DA B did not wash her hands when leaving and reentering the kitchen. She stated not washing hands could lead to cross-contamination and spread infection. Residents Affected - Many During an interview on 06/26/23 02:36 PM, the ADMIN stated her expectation was for hand washing to be performed every time when entering the kitchen, and anytime you went from dirty to clean. She stated hand washing was very important to prevent the spread of infection. She stated DM A was responsible for training the dietary staff. She stated the failure probably occurred because DA B was nervous but obviously more training needed to be done. Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Sanitation and Food Handling, dated 2012, read in part All employees wash your hands with soap and water before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning. Review of FDA Food Code of 2022 revealed: 2-301.14 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; .(D) after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 675319 Page 6 of 8 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurate for 2 of 3 residents (Resident #36 and Resident #149) reviewed for resident records. The facility failed to document the verification of placement of a wanderguard each shift, and the function of resident's device daily for Resident #36 and Resident #149. This failure could place residents at risk of residents having errors in care and treatment. Findings include: Review of Resident #36's face sheet, dated 06/28/2023, revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis Dementia. review of Resident # 36's Quarterly MDS, dated [DATE], revealed: Section C- Cognitive Behavior a BIMS score of 8 meant he had moderate cognitive impairment. Review of Resident #36's electronic medical record revealed no evidence of documentation of verification of placement of a wanderguard documented each shift, or documentation of the function of resident's device verified at least daily. Review of Resident #149's face sheet, dated 06/28/2023, revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis Dementia and Anxiety. Review of Resident # 149's admission MDS, dated [DATE], revealed no evidence of a BIMS score. Review of Resident #149's electronic medical record revealed no evidence of documentation of verification of placement of a wanderguard documented each shift, or documentation of the function of resident's device verified at least daily. Observation on 06/28/2023 at 11:10 AM revealed Resident #36 was wearing a wanderguard on the right ankle and Resident #149 was wearing a wanderguard on right wrist. During an interview on 06/28/2023 at 5:03 PM the DON stated her expectation was that wanderguards should have been checked for placement and documented every shift in the electronic chart and wanderguard function should have been checked daily and also documented in electronic chart. The DON stated not checking placement every shift could have affected residents by resident skin not being assessed, wanderguard not placed properly or the wander guard not working . During an interview on 06/28/23 at 5:14 PM, the ADMN stated her expectation was that there should have been documentation of placement of wanderguards every shift and functionality of wanderguards documented daily. The ADMN stated the nurses were responsible to ensure wanderguards were being verified for placement and documented each shift. The ADMN stated not checking placement each shift or functionality of wanderguard could have caused skin issues. The ADMN stated staff assuming appropriate documentation was completed led to failure of the wanderguards not being verified. 675319 Page 7 of 8 675319 06/28/2023 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0842 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Elopement Prevention, dated 10/27/10, revealed Wanderguard System (locking or alarming) Placement of the resident's device to alarm the system will be verified each shift and documented on the treatment or other flow record. Function of the resident' s device will be verified at least daily and documented on the treatment of other flow record. Residents Affected - Some 675319 Page 8 of 8