Health inspection·August 20, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal 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 for 2 of 14 residents (Resident #8 and Resident #30) reviewed for resident rights. Residents Affected - Some The facility failed to ensure Residents #8 and Resident #30 were given a paper copy of the NOMNC (notice of Medicare non coverage) with information on how to appeal the decision when residents were 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 their right to appeal the decision to end Medicare coverage for skilled services, changes to provided services, and their financial responsibilities. Findings included: Resident #8 Record review of Resident 8's electronic face sheet dated 08/20/2024 revealed resident was an [AGE] year-old female who was initially admitted on [DATE] with diagnoses that include: enterocolitis due to clostridium difficile (inflammation in the bowl due to infection) sepsis (body's extreme reaction to an infection), UTI (urinary tract infection, hypertension (high blood pressure), and weakness. Record review of Resident #8's admission MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 11 meaning moderate cognitive impairment. Further review of the MDS revealed Resident #8 sometimes needed help with written material instructions. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #8 received Medicare Part A Skilled Services on 02/29/2024 and her last covered day of Part A services was 04/08/2024. The SNF Beneficiary Protection Notification Review indicated the discharge was voluntary from Medicare Part A Services when benefit days were not exhausted. Record review of Resident #8's NOMNC dated 04/05/2024 revealed the facility spoke with Resident #8's family member to go over NOMNC. A signature from the patient or representative was on NOMNC form. There was no evidence that form was given to patient or representative. During a telephone interview on 08/20/2024 at 9:37 a.m., Resident #8's family stated she did not Page 1 of 16 675319 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0582 Level of Harm - Potential for minimal harm Residents Affected - Some remember receiving any paperwork about Medicare coverage ending. Resident #8's family denied getting a phone call going over Medicare coverage ending. She stated she did not receive an appeal number. Resident #30 Record review of Resident 30's electronic face sheet dated 08/20/2024 revealed resident was a [AGE] year-old male who was originally admitted on [DATE] with diagnoses that include: atherosclerosis of coronary artery bypass graft(s) without angina pectoris (occlusion of heart artery after it has had surgery to bypass in the past without chest pain), intracardiac thrombosis (blood clot in the heart), congestive heart failure (less blood is pumped through the heart and around the body due to weakened heart, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (inability to move or weakness to right dominant side following stroke), transient cerebral ischemic attack (mini stroke), and cellulitis (skin infection). Record review of Resident #30's admission MDS dated [DATE] revealed Resident #30 had a BIMS score of 00 meaning severe cognitive impairment. Further review of MDS revealed Resident #30 had moderate difficulty hearing, unclear speech, and sometimes able to make self-understood. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #30 received Medicare Part A Skilled Services on 04/15/2024 and his last covered day of Part A services was 05/16/2024. The SNF Beneficiary Protection Notification Review indicated the discharge was voluntary from Medicare Part A Services when benefit days were not exhausted. Record review of Resident #30's NOMNC dated 05/14/2024 revealed the facility spoke with Resident #30's family member his RR to explain NOMNC. There was no signature from patient or representative on the NOMNC form. There was no evidence the form was given to the patient or representative. During a telephone interview on 08/20/2024 at 9:46 a.m., Resident #30's family stated she did not receive any paperwork about Medicare coverage ending. She stated she did remember a conversation about Medicare coverage ending but did not receive an appeal number. During an interview on 08/09/2024 at 2:57 p.m., the MDS coordinator stated she would call the resident's representative if they were unable to be present to hand them the NOMNC form for signature and the resident was unable to sign themselves. She stated she explained the NOMNC including the last covered Medicare date and verified the discharge date with the representative over the phone. She stated she did not mail the paper form to the RR. She stated the RR was allowed to ask questions over the phone and she would give them the appeal number verbally if they asked for it. The MDS coordinator stated if the RR was present in person, then the form was provided to them. During an interview on 08/20/2024 at 8:20 a.m., the ADMN stated the facility would call family if family were not available in person to sign the NOMNC. Verbal notification would be documented but she was unsure if the NOMNC form was mailed by the MDS coordinator to family. She stated residents and their representative were notified of the NOMNC and stated she felt verbal explanation was more important than given the individual a piece of paper. She stated no one had ever asked for the NOMNC form after verbal explanation. She stated she was unaware the paper form was to be mailed to individual if verbal explanation was provided over the telephone. She stated both her and the MDS coordinator monitored that NOMNCs were done, and she would give the NOMNC information to the resident or their representatives if the MDS coordinator was not working that day. She denied any negative effect to residents from not providing the NOMNC form and stated the facility would help the representatives 675319 Page 2 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0582 with the appeal if the resident or their representative voiced that they wanted to appeal. Level of Harm - Potential for minimal harm Review of facility policy titled Creative Solutions in Healthcare Advanced Beneficiary Notice NOMNC P&P with revision date of May 2024 revealed: Residents Affected - Some Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. Providers nay formally delegate the delivery of the notices to a designated agent such as a courier service; however, all of the requirements of valid notice delivery apply to designated agents. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature . If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. 675319 Page 3 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 3 of 14 residents (Resident #5, Resident #12, and Resident #37) reviewed for PASRR. The facility failed to follow up with the LA for PASRR Level II determination when Resident #5, Resident #12, and Resident #37s PASRR Level 1 Screening reflected they were positive for mental illness. This failure could place the residents with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services. Findings included: Resident #5 Record review of Resident #5's electronic face sheet dated 08/20/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #5 had diagnoses of psychosis with onset date of 01/22/2021 and diagnosis of major depressive disorder added with onset date of 01/26/2021. Resident #5 had secondary diagnosis of dementia added with onset date of 01/17/2023. Record review of Resident #5's medical record revealed no evidence a PASRR evaluation had been performed. Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 15 meaning cognition was intact. Further investigation revealed active psychiatric / mood disorder of depression and psychotic disorder. Record review of Resident #5's care plan dated 07/12/2024 revealed Resident #5 had impaired cognitive function / impaired thought processes r/t psychosis, and mood problem r/t depression, personality change and adjustment disorder. Resident #12 Record review of Resident #12's electronic face sheet dated 08/20/2024 revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #12 had diagnosis of psychosis with onset date of 10/01/2022 and major depressive disorder with onset date of 05/10/2021. Resident #12 had other diagnosis of dementia with onset date of 08/20/2024. Record review of Resident #12's medical record revealed no evidence a PASRR evaluation had been performed. Record review of Resident #12's quarterly MDS dated [DATE] revealed Resident #12 had a BIMS score of 05 meaning severe cognitive impairment. Further review revealed active diagnosis of depression and post-traumatic stress disorder. 675319 Page 4 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #12's care plan dated 08/12/2024 revealed Resident #12 had depression r/t major depressive disorder and a behavior problem. Resident #37 Record review of Resident #37's electronic face sheet dated 08/20/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #37 had diagnosis of psychosis with onset date of 11/06/2023 and major depressive disorder onset date of 06/06/2023. Resident #37 had secondary diagnosis of dementia with onset date of 06/06/2023. Record review of Resident #37's medical record revealed no evidence a PASRR evaluation had been performed. Record review of Resident #37's annual MDS dated [DATE] revealed Resident #37 had a BIMS of 01 meaning severe cognitive impairment. Further review revealed active diagnosis of depression. Record review of Resident #37's care plan dated 08/18/2024 revealed Resident #37 required antidepressant medication r/t major depressive disorder and a psychosocial well-being problem r/t anxiety / depression. During an interview on 08/20/2024 at 8:43 a.m., the MDS coordinator stated major depressive disorder did not qualify as a mental illness. She stated once the PASRR level 1 was completed with a negative response for mental illness, a new diagnosis that would qualify as mental illness should have triggered the facility to initiate a new form for PASRR evaluation to be performed. She stated when a resident had a dementia diagnosis and mental illness diagnosis then the resident would not be flagged for a PASRR evaluation. She stated she would look to see if PASRR evaluations had been performed. During a follow up interview on 08/20/2024 at 9:01 a.m., the MDS coordinator stated nursing considered major depression as a mental illness. She stated she was unsure if major depressive disorder would qualify as mental illness on a PASRR level 1 form. She clarified dementia would need to be primary diagnosis for dementia to override a PASRR evaluation. She did not feel that a PASRR evaluation should have been done but would ask facility's corporate MDS coordinator for more guidance. During a follow up interview on 08/20/2024 at 9:28 a.m., the MDS coordinator stated she spoke with the facility's corporate via telephone and was instructed that a 1012 form (used by nursing facilities to determine if a previously negative PASRR level 1 screening form needs to be changed to a positive PASRR level 1 for mental illness) should have been completed after a new diagnosis qualifying as mental illness but the form would a need physician's signature and she was unsure that Resident #5's physician would sign the 1012 form. She stated that she did notify the local authority and a PASRR evaluation was in the process of being scheduled. She stated she was unaware of the rules the facility should have followed when a new mental illness diagnosis had been added to have the PASRR evaluation scheduled after the first PASRR level 1 form was completed. During an interview on 08/20/2024, the ADMN stated she expected for staff to follow the PASRR policy. She stated she expected when a significant change occurred with new diagnosis for a PASRR evaluation to be performed. She stated the MDS coordinator and Regional Corporate MDS coordinator was who monitored PASRR completion. She stated no effect on the residents occurred due to they were receiving care and psychiatric services from the facility. She stated lack of knowledge and oversight led to failure. 675319 Page 5 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0644 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled PASRR Nursing Facility Specialized Services Policy and Procedure dated 03/06/2019 revealed: 1. PL1 is completed 2. If PL1 is coded as suspicion of MI, ID, DD, then a PE is required. Residents Affected - Some 675319 Page 6 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 (Resident # 6 and Resident #17) reviewed for oxygen therapy. Residents Affected - Some The facility failed to ensure that oxygen tubing and nasal cannula were placed in plastic bag for 2 of 2 residents (Resident #6 and Resident #17) when not in use. These failures placed residents of the facility at risk for respiratory illnesses. Findings included: During an observation on 08/18/2024 at 2:25 PM RM [ROOM NUMBER] revealed Oxygen tubing with nasal cannula on bedside table and not in a plastic bag. Resident #6 was not in the room at the time. Resident #6 During a review of Resident #6 's electronic face sheet revealed: [AGE] year-old female admitted on [DATE] with diagnoses of Anorexia (eating disorder), Dysphagia (difficulty swallowing), Cognitive communication deficit, and Hypertension (high blood pressure) During a review of Resident #6 's Physician orders date 08/01/2024 revealed: Oxygen at 2 LPM (liters per minute) via nasal cannula to keep oxygen saturation above 90%. During a review of Resident #6's Quarterly MDS dated [DATE] revealed: Section Cognitive Patterns BIMS score was 8 indicating Moderately impaired cognitive status and Section O-Special Treatments, Procedures, and Programs-Oxygen Therapy while a resident. During a review of Resident #6's Care plan dated 06/11/2024 revealed: Focus-The resident has Oxygen Therapy. Goal: The resident will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Notify the nurse if the oxygen is off the resident-resident frequently removes O2. Oxygen at 2 liter per minute per nasal canula. During an observation on 08/18/2024 at 2:25 PM, revealed Resident #6's oxygen tubing with nasal cannula on the bedside table was not in a plastic bag. Resident #6 was not in the room at the time. Resident #17 During a review of Resident #17's electronic face sheet revealed: [AGE] year-old male admitted on [DATE]. Diagnoses include Chronic Obstructive Pulmonary Disease (lung disease), Hypertension (high blood pressure), Anxiety. During a review of Resident #17's Physician Orders dated 08/01/2024 revealed: May use oxygen at 2-3 liters per minute via nasal canula. Change nasal canula as needed, check oxygen saturation every shift and as needed. 675319 Page 7 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident #17's Quarterly MDS dated [DATE] revealed: Section C-cognitive Patterns BIMS score was 12 indicating moderately impaired cognitive status. Section O- Special Treatments, Procedures and Programs, C 1. Oxygen Therapy while a resident. During a review of Resident #17's Care Plan dated 08/05/2024 revealed: Focus The resident has Oxygen Therapy. Goal: The resident will have no signs/symptoms of poor oxygen absorption through the review date. Interventions- for residents who should be ambulatory, proved extension tubing or portable oxygen apparatus. Oxygen 2-3 liters per minute per nasal canula. During an observation on 08/18/2024 at 3:25 PM RM [ROOM NUMBER], revealed Resident #17's oxygen tubing with the nasal cannula was on the floor and not in a plastic bag. Resident #17 was not in the room at this time. During an interview on 08/20/2024 at 10:25 AM with the DON. The DON stated oxygen tubing with nasal canula should not be on a table or on the floor. The DON stated oxygen tubing and nasal canula should be changed when they are visibly soiled. The DON stated when oxygen tubing is found on the floor it should be thrown away and replaced with clean oxygen tubing. The DON stated her expectations were that oxygen tubing would be placed in a plastic bag when not in use by the resident. The DON stated not replacing oxygen tubing and nasal canula after being found on the floor could possibly cause the resident to acquire an infection. The DON stated she did not know why this failure occurred. During a review of facility's policy titled Oxygen Administration dated March 21, 2023 Oxygen therapy includes the administration of oxygen (O2) in liters/minute by cannula or face mask . Goals 3. The resident will be free from infection. Procedure: 10. Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated . Review of facility's policy titled Hand Hygiene (no date) You may use alcohol-based hand cleaner or soap/water for the following . Before and after assisting a resident with meals Upon and after coming in contact with a resident's intact skin . 675319 Page 8 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based upon observation, interview and record review, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors for 2 of 3 days reviewed for nursing services and postings. Residents Affected - Many The facility failed to ensure daily staffing information was posted in a prominent place on 08/18/2024 and 08/19/2024. This failure places residents, their families, and visitors at risk of not having access to information regarding staffing and facility census. Findings include: During an observation of postings in the facility on 08/18/2024 at 2:00 PM, revealed no daily nursing staffing information posted at the nurses' station or any other place in the facility. During an observation of postings in the facility on 08/19/2024 at 8:30 AM, revealed no daily nursing staffing information posted at nurses' station or any other place in the facility. During an interview on 08/20/2024 at 4:30 PM, the DON stated she did not know she was supposed post the daily staffing. The DON stated she did feel that this would not cause any harm to residents. The DON stated family, residents or visitors could ask what staff were working. The DON stated the failure occurred due to her not knowing she was supposed to display the daily staffing data. The DON stated they did not have a policy for nurse staff posting and they followed the federal regulations. 675319 Page 9 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #22) reviewed for meals. The facility failed to ensure that Resident #22 was served a pureed bowl of melon, instead of a bowl of regular melon. This deficient practice could affect residents by placing them at risk for choking and weight loss. The findings were: Record review of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnoses include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), and Abnormal weight loss. Record review of Resident #22's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns Resident #22 had a BIMS score of 00 indicating had severe cognitive impairment; Section KSwallowing/Nutritional Status Resident #22 was on mechanically altered diet. Record review of Resident #22's Care plan dated 08/18/2024 revealed: Focus-Resident has Fortified/ Enhanced Pureed diet and has a planned weight gain Record review of Resident #22's Physician's Orders dated 08/01/2024 revealed: Fortified/Enhanced diet, pureed (all food has been ground, or strained to a soft, smooth consistency, like pudding) texture. During an observation on 08/18/2024 at 5:57 PM revealed Resident #22 was served a bowl of melon that was not pureed. Resident #22 picked up a piece of the melon and put a part of the melon in her mouth and then removed the melon. Resident #22 did not show any sign of distress or coughing . During an observation and interview on 08/18/2024 the RNC stated Resident #22 should have not had a regular bowl of melon, it should have been pureed melon and removed the bowl of melon and provided Resident #22 a pureed dessert. During an interview on 08/19/2024 at 12:39 PM the Dietician stated she expected for residents who were on a pureed diet should have been served pureed fruit. The Dietician stated that she believed the incident was a single incident. The Dietician stated she did not know why the melons were not served pureed to Resident #22. The Dietician stated kitchen staff should have verified the resident's specific diet and had placed the correct food on the tray, before it left the kitchen, and the dining room staff should have checked that the correct diet was served prior to the resident being served. The Dietician stated serving the wrong diet could have led to harm including choking and pneumonia. During an interview on 08/20/2024 at 4:30 PM the ADMN stated her expectation was residents who had an order for a pureed diet should have received a pureed diet. The ADMN stated the kitchen staff and 675319 Page 10 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing staff were responsible to monitor that residents received the proper diet. The ADMN stated the effect on residents not receiving the proper diet could have caused residents to choke. The ADMN stated what led to failure was staff were nervous and oversight by staff. Record review of facility policy titled, Feeding, Assistive/Complete dated February 14, 2007, revealed: The resident will be free from aspiration . Review diet orders and tray card to confirm appropriate diet. 675319 Page 11 of 16 675319 08/20/2024 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 in 1 of 1 kitchen reviewed for food safety. The facility failed to provide paper towels at the kitchen hand washing sink. The facility failed to label stored foods with a description and/or open date. The facility failed to store foods with lids that covered the food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 08/18/2024 between 02:10 PM and 2:30 of the kitchen revealed: 1. The hand washing sink in the kitchen did not have paper towels available to dry hands. 2. An opened container of cake frosting was sitting in a sealed see through bag with no opened date in 1 of 1 dry storage. 3. An opened bag of cream soup base was in a sealed see through bag with no opened date in 1 of 1 dry storage. 4. A circular frozen breaded product was in a sealed see through bag in 1 of 2 freezers with no description or opened date. 5. 1 box of frozen pie dough sheets was opened, the plastic bag was not sealed which exposed product to air in 1 of 2 freezers with no opened date. 6. Pink frozen meat cutlets in a sealed see through bag in 1 of 2 freezers had no description or opened date. 7. 675319 Page 12 of 16 675319 08/20/2024 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 1 foam cup with a pink substance was sitting on a shelf in 1 of 1 refrigerator with no lid, description or opened date. 8. 3 plastic dishes with a yellow substance were sitting on shelf in 1 of 1 refrigerator with a smaller lid than the dishes, no description or date prepared. During an interview on 08/18/2024 at 02:42 p.m., the DM stated she expected for food to be stored in a sealed container after being opened. She stated items should be dated when they were opened. She stated the kitchen sink should have paper towels for staff to dry their hands and to turn off the faucet. She was unsure why items were not covered and dated when stored. She was unsure why faucet did not have paper towels available for staff. She stated she was responsible for monitoring foods stored appropriately and all kitchen staff monitor that there are paper towels available at the sink with housekeeping. During a follow up interview on 08/18/2024 at 06:00 p.m., the DM stated staff were in-serviced on food storage prior 08/18/2024 and that included the need to cover items completely when stored in refrigerator and labeling items. She stated not covering food items completely and not having paper towels to dry hands could lead to food borne illness from cross contamination. During an interview on 08/19/2024 at 12:42 p.m., the Dietician stated she expected for all foods that are stored outside of original packaging to have a label with item description. She stated foods should have been labeled with an open date when they had been opened. She stated that foods should be labeled with preparation date when they were stored. She stated all foods should have been stored in a secure bag or lid that covered the food. The Dietician stated she expected for there to be paper towels to dry hands and turn off the faucets at hand washing sink. She stated staff had just been in-serviced on food storage and how to cover foods completely, so she did not know why foods were not stored appropriately. She stated not storing foods appropriately and not having proper hand drying material could cause illness to residents from cross contamination. She stated the DM monitored that foods are stored properly. Record review of facility policy titled Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened .These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated .If a frozen food does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging. Record review of facility policy titled Hand Washing dated 2012 revealed: Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 8/20/24): 675319 Page 13 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0812 2-301.1 Cleaning procedure. Level of Harm - Minimal harm or potential for actual harm Every stage in handwashing is equally important and has an additive effect in transient microbial reduction. Therefore, effective handwashing must include scrubbing, rinsing, and drying the hands. When done properly, each stage of handwashing further decreases the transient microbial load on the hands. It is equally important to avoid recontaminating hands by avoiding direct hand contact with heavily contaminated environmental sources, such as manually operated handwashing sink faucets, paper towel dispensers, and rest room door handles after the handwashing procedure. This can be accomplished by obtaining a paper towel from its dispenser before the handwashing procedure, then, after handwashing, using the paper towel to operate the hand sink faucet handles and restroom door handles . Residents Affected - Many 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient . 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 675319 Page 14 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on interviews, and record reviews, the facility failed to ensure professional staff was certified in accordance with applicable State laws for 1 (NA B) of 15 personnel reviewed for licensed nursing. Residents Affected - Few The facility failed to ensure NA B had become a Certified Nurse Aide by passing her certification test. These failures could place residents at risk of being provided care by staff who are not qualified per state law. Findings included: Record review of NA B's employee file revealed a hire date of 08/30/2022 and no evidence of CNA certification. During an interview on 08/20/24 at 3:21 PM the DON stated that NA B was a NA and not a CNA. The DON stated NA B was currently enrolled in an online course. The DON stated NA B had failed the CNA certification exam twice before and had one more attempt. The DON stated her expectation was for her to complete the online course and pass her test in a timely manner. The DON did not think there was an effect on residents because NA B always worked with a CNA (who was certified). The DON stated what led to failure of NA not being certified was she could not pass because of nerves. During an interview on 08/20/2024 at 4:30 PM the ADMN stated her expectation was for NAs to become certified as quickly as possible. The ADMN stated the DON was to monitor to ensure NAs completed test and became certified. The ADMN stated what led to failure was NA took a program from a high school and she was not sure how well it prepared NA for the test. The ADMN stated they had been waiting for the state provided online class to begin so the NA could retake class and complete the test. Record review of facility provided job description, titled Job Description Student Nurse Aide, dated 2014 revealed; I understand that this position is not permanent but limited to 120 days in which I am required to test and obtain certification. 675319 Page 15 of 16 675319 08/20/2024 Deleon Nursing and Rehabilitation 809 E Navarro DE Leon, TX 76444

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 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 diseases and infections for 1 of 1 residents LVN A feeding 1of 1 residents (Resident #22) did not perform hand hygiene after touching resident and wiping resident mouth. Residents Affected - Few The facility failed to ensure proper hand hygiene when feeding a resident (Resident #22). These failures placed residents of the facility at risk of infections from respiratory care and dining. Findings included: During a record review on 08/20/2024 of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnosis include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), Abnormal weight loss. During a record review on 08/20/2024 of Resident #22's Physician Orders dated 08/01/2024 revealed: Fortified/Enhanced diet, pureed (all food has been ground, or strained to a soft, smooth consistency, like pudding) texture. During a record review on 08/20/2024 of Resident #22's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns BIMS score was 00 meaning Resident #22 had severe cognitive impairment. During a record review on 08/20/2024 of Resident #22's Care plan dated 08/18/2024 revealed: Focus-The resident has an ADL (activities of daily living) self-care performance deficit. Goal: the resident will maintain or improve current level of function in Eating . Interventions: Eating: assist x 1. During an observation on 08/18/2024 at 5:57 PM in facility dining room revealed LVN A feeding Resident #22. Observed LVN A sitting between two residents assisting both residents with their meals. LVN A assisted on resident and the assist another resident. LVN A touched one resident and wiped the resident's mouth and did not perform hand hygiene before continuing to assist residents with their meals. LVN A touched the back of Resident #22's chair and picked up a spoon and continued to assist resident with eating without performing hand hygiene before assisting Resident #6 with meal. During an interview on 08/18/2024 at 5:57 PM with LVN A. LVN A stated she had been doing this for a long time and did not even think about it. She stated she failed to hand sanitize when she touched the resients back and face and helped her wipe her face. Review of facility's policy titled Hand Hygiene (no date) You may use alcohol-based hand cleaner or soap/water for the following . Before and after assisting a resident with meals Upon and after coming in contact with a resident's intact skin . 675319 Page 16 of 16