Health inspection·August 24, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 resident rooms (Resident #13, 29, and 84) observed for a clean environment. The facility failed to ensure that resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Workers' Checklist. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas. Findings include: Observation on 08/22/23 at 11:35 AM, in Resident # 84's room revealed the bathroom in the resident's room had dried up Fecal matter on the top left side of the toilet. The bottom portion of the toilet had dark dirt stains on around it. An interview with Resident # 84 (BIMS: 15) revealed, she had asked two CNAs (could not remember names) to clean the toilet earlier in the morning, after her roommate had messed it up and no one had yet to clean the toilet. Resident #84 stated the site of the toilet was gross. Observation on 08/22/23 at 11:43 AM, of Resident # 29's room revealed, the resident's bathroom was observed to had large dirt stains on the outer lower toilet and in the corner of the bathroom floors. Observation on 08/22/23 at 11:43 AM, Resident # 13's room revealed, the resident's room had some drywall of repaired completed and the area still had the dirt and dust from the repair. Interview with Resident # 13 (BIMS: 25) at 11:43 AM, revealed she had stated maintenance had made repairs to the wall a few months ago but she was not sure when. She stated she did not focus on the dirt because she kept the curtains closed in the area of the room. Interview with Housekeeping Services M on 08/22/23 at 11:51 AM, revealed she was assigned the 400 Hall and she stated that she cleaned rooms daily. She advised that she was not provided a checklist and just cleans whatever needs to be cleaned. She advised that she was also not trained on what areas to clean but to clean from top to bottom. She advised the risk of not cleaning room thoroughly could result in residents getting sick. Page 1 of 15 675447 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Environmental Service Director on 08/24/23 at 12:00 PM revealed, he was shown pictures of concerns observed in the facility. He advised that he had trained his housekeeping staff on cleaning from top to bottom, which included wiping down the walls, cleaning the bathrooms thoroughly, and ensuring the entire floor was properly swept and mopped. He admitted to making the repairs to Resident #13's room wall and he stated he forgot to ensure it was cleaned up. He stated he had numerous discussions with Housekeeping Services M about not thoroughly cleaning rooms and she would be disciplined. He advised the risk of not properly cleaning the room could result in an Infection for residents. Interview with Assistant Administrator on 08/24/23 at 12:55 PM, revealed she was shown the pictures of the concerns observed in the facility for cleanliness. She advised she had met with the Environmental Services Director to discuss the concerns. She advised that for the most part, her housekeeping staff had an opportunity to improve in being more consistent with the cleanliness of the rooms. She advised the risk of not ensuring rooms were cleaned thoroughly is a sanitary concern and also infection control based on the health of the resident. Review of the facility's Housekeeping Workers' Checklist dated 7/2017, revealed that the residents' room were expected to be cleaned daily, including the cleaning of all fixtures and furniture, walls, and dusting and mopping floors. 675447 Page 2 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to secure the catheter to facilitate flow of urine, prevent kinking of the tubing and position below the level of the bladder for 1 (Resident #57) of 1 resident observed for urinary catheter care. The facility failed to ensure CNA E kept the urine collection bag of Resident #57 below the level of the bladder. These failure could place the resident at risk for infection development. Findings included: Review of Resident #57's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified neuromuscular dysfunction of bladder, cognitive communication deficit, and unspecified osteomyelitis. Review of Resident #57's Comprehensive MDS dated [DATE] reflected that Resident #57 has no BIMS score because resident was unable to complete the interview. Resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident was totally dependent for eating and bathing. The bladder and bowel section of the Comprehensive MDS also indicated the use of indwelling catheter. Review of Resident #57's Comprehensive Care Plan dated 05/26/2023 reflected that resident had an ADL self-care performance deficit r/t (relate to) Cerebral infarction. Review of Resident #57's Comprehensive Care Plan dated 05/26/2023 reflected that resident had (Indwelling) Catheter: Neurogenic bladder. 16FR 10ml Review of Resident #57's Physician's order dated 05/19/2023 reflected, Foley catheter size: 16fr with 10 ml balloon inflation and diagnosis. Observation on 08/22/2023 at 10:51 AM, revealed that Resident #57 was resting in her bed. The resident had an above the knee amputation to the right leg. The Hoyer lift sling was under the resident. The resident's urine collection bag was on top of the bed below the amputated leg. The catheter tubing was in a U-shaped formation. The urine in the tubing was in the direction towards the resident. Observation on 08/22/2023 at 11:22 AM, revealed that Resident #57 was still in the bed. The urine collection bag was still on top of the bed. Observation on 08/22/2023 at 11:31 AM, revealed that Resident #57 was to be transferred to the wheelchair via Hoyer lift. The urine catheter bag was on top of the bed prior to transfer. Interview with CNA E on 08/22/2023 at 11:32 AM, CNA E stated that she was the CNA for hall 200 for that day. She stated that she was the one who prepared Resident #57 that morning. CNA E said that she placed the urine collection bag on the bed to be able to put the pants on Resident #57. CNA E acknowledged that she should have hooked the urine collection bag back to the railing at the bottom of 675447 Page 3 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the bed if she was not yet to be transferred to the wheelchair. CNA E stated that leaving the urine collection bag on top of the bed could cause the urine to go back. This could cause urinary tract infection. Interview with LVN A on 08/23/2023 at 10:44 AM, LVN A said that Resident #57 is an amputee, a diabetic, with continuous feeding, and has an indwelling catheter. He added that the catheter bag should be hanged on the rail at the bottom of the bed. The catheter bag should be below the bladder so the flow of the urine will not be disrupted. LVN A further stated that if the urine flow is disrupted, it will not flow to the catheter bag and might go back. It could cause problems in the abdomen and infections such as urinary tract infection. Interview with ADON N on 08/23/2023 at 11:50 AM, ADON N stated that the catheter should not be on the bed because it could cause infection such as urinary tract infection. She stated that if the catheter bag was placed on the bed to facilitate dressing change, the catheter bag should not stay on the bed for a long time. ADON N said that the catheter bag should be hooked back to the bottom of the bed if the resident will not be transferred yet. It should not stay on the bed for a long time because it could result to urine backflow. Interview with the DON on 08/24/2023 at 8:43 AM, DON stated that the catheter should not be on the bed. She said that this action could cause the urine to flow back. The urine backflow could result to urinary retention and urinary tract infection. DON stated that this is not acceptable, and everybody must do better. DON said that all staff were expected to follow the infection control policy. She added that they did an in-service on 08/23/2023 to address the infection control issues. The in-service was to educate and remind the staff about the policy for infection control. Interview with the Assistant Administrator on 08/24/2023 at 10:01 AM, Assistant Administrator stated that the expectation was for the staff to follow the policies and procedures of the facility in general. She said the residents should feel safe and living to their full potential. The Assistant Administrator said that all staff should adhere to what is the best standard of care. Interview with CNA H on 08/24/2023 at 10:47 AM, CNA H stated that when transferring a resident with a catheter, the catheter should be hooked at the bottom of the wheelchair. The catheter bag should not be left on the left on the bed because it would cause the urine to go back and could cause infection. Interview with CNA D on 08/24/2023 at 10:52 AM, CNA D stated that the catheter bag should not be placed on top of the bed. The catheter bag should be hooked on the railing below the bed. CNA D said that the urine that is already contaminated will go back and could cause infection. Record review of facility policy, Catheter Care, Urinary, Med-Pass Inc., rev. September 2014 revealed Maintaining Unobstructed Urine Flow . 3. The urinary drainage bag must be held or positioned lower that the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 675447 Page 4 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to ensure that 2 of 2 residents (Resident #16 and Resident #30) were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure CMA C re-ordered medications on a timely manner for Resident #16 (Duloxetine 60 mg) and Resident #30 (Pravastatin 40 mg). This failure placed the residents at risk of not receiving medications as ordered by the physician. Findings included: Review of Resident #16's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia, and major depressive disorder. Review of Resident #16's Quarterly MDS dated [DATE] reflected that resident #63 was cognitively intact with a BIMS score of 15. Resident required extensive assistance for bed mobility, transfer, locomotion in unit, dressing, toilet use, and personal hygiene. Supervision required for eating. The quarterly MDS also indicated depression as one of the primary medical condition. Review of Resident #16's Comprehensive Care Plan dated 08/16/2023 reflected that resident had impaired thought processes r/t (related to) disease process Dx (diagnosis) major depressive disorder. Review of Resident #16's Physician's order for duloxetine 60 mg dated 08/07/2023 reflected, Give 1 capsule by mouth two times a day for depression. Review of Resident #30's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia, and type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral. Review of Resident #30's Comprehensive MDS dated [DATE] reflected that resident #30 has severe impairment in cognition with a BIMS score of 07. Resident required supervision for bed mobility, transfer, walk in room, walk in corridor, locomotion in unit, locomotion off unit, dressing, eating, toilet use, bathing, and personal hygiene. The comprehensive MDS also indicated hyperlipidemia as one of the primary medical condition. Review of Resident #30's Physician's order for pravastatin 40 mg tablet dated 05/26/2023 reflected, Give 1 tablet by mouth at bedtime for HLD (high lipid density). Observation on 08/23/2023 at 8:43 AM revealed that CMA C prepared and administered medications to Resident #16. Resident #16's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for duloxetine 60 mg showed only two capsules. Observation on 08/23/2023 at 8:40 AM revealed that CMA C prepared and administered medications to 675447 Page 5 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0755 Resident #30. Resident #30's blister pack for pravastatin 40 mg showed only one tablet. Level of Harm - Minimal harm or potential for actual harm Interview with LVN A on 08/23/2023 at 10:44 AM, LVN A stated that medications should be re-ordered as soon as medications reached the blue portion of the blister pack. LVN A said that medications should not be re-ordered on the last minute because the residents will not have sufficient supply of medication in situations that the delivery was delayed. LVN A further added that this could worsen the residents' medical situation. Residents Affected - Few Interview with CMA C on 08/23/2023 at 11:04 AM, CMA C stated that the time to re-order medications is when the medication reached the blue portion of the blister pack. CMA C acknowledged that sometimes she would wait until the medications were midway the blue portion of the blister pack before she would re-order. When asked what should be done to the blister packs of Resident #16 (Duloxetine 60 mg) and Resident #30 (Pravastatin 40 mg), CMA C replied that she should re-order them right away. Interview with ADON N on 08/23/2023 at 11:50 AM, ADON N stated that there are two ways to re-order medications. The first one is re-ordering through the computer. The CMA had access to do it. The second one is by placing the sticker from the blister pack of the medication in a form provided by the pharmacy. The form is then faxed to the pharmacy. ADON N said that the CMA should re-order when the medication reached the blue part of the blister pack. ADON N stated that the medications should be re-ordered in a timely manner to make sure that the residents have enough supply of medications. Interview with the DON on 08/24/2023 at 08:43 AM, DON stated that the staff must make sure that the medications were re-ordered on a timely manner to make sure that the residents have the medications they need. It is not acceptable that residents did not have their medications because the medications were not re-ordered when it was supposed to be re-ordered. The DON stated that the expectation is that all staff would follow the procedure, adhere to the policy, and do the best standard of practice. DON also added that an in-service was done on 08/23/2023 to address this issue. Interview with Assistant Administrator on 08/24/2023 at 10:01 AM, Assistant Administrator stated that the expectation is for the staff to follow the policies and procedures of the facility in general. She said the residents should feel safe and living to their full potential. Assistant Administrator said that all staff should adhere to the best standards of care. Record review of facility policy, Medication Ordering and Receiving from Pharmacy, American Society of Consultant and Med-Pass Inc., rev. January 2018 revealed Procedures . A. Ordering Medications from Dispensing Pharmacy . 2) If not automatically refilled by the pharmacy . reorder medications three to four days in advance of need .to assure an adequate supply in on hand. 675447 Page 6 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure the Ice machine, Ice Scooper, and Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 08/22/23 at 09:15 AM in the facility's only kitchen include: Ice Machine was dirty on the inside of the ice machine and the machine was filled with ice. The top portion, over the ice, had dirt stands on the inner white plastic part of the machine that was over the ice and the Ice Machine door had a lot of old dirt particles in the springs of the door hinge. Ice Machine Scoop Holder was dirty on the inside and had a lot of dirt particles dried up on the bottom of the Ice holder. One 5 lb. tubing of what appeared to be ground beef was undated and unlabeled in the refrigerator. The tubing had no visible expiration date. Two small containers of Kosher meat were unlabeled and undated in the refrigerator. The containers had no visible expiration date. 6 containers of Kosher meals were unlabeled and undated in the refrigerator. The containers had no visible expiration date. Interview and observation with Kitchen Dietary Manager on 08/22/23 at 09:15 AM, revealed he was overall responsible for ensuring the kitchen was complying to Federal and State guidelines. He stated that he had the Ice machine, Ice Scooper, and Ice Scooper Holder cleaned at least once a month, but had not been checking for cleanliness recently, but would ensure that it was cleaned immediately. He was shown the foods that were unlabeled and undated, and he stated that when they got food delivered, he normally ensured his staff labeled and dated the foods as they are being stored, but his team had missed some items. He stated the risk of not ensuring all these concerns were addressed could result in residents getting ill as a result of food contamination. Interview with Assistant Administrator on 08/24/23 at 10:55 AM, revealed she was shown the pictures of the concerns discovered in the facility's only kitchen. She advised that the Dietary Manager had notified her of the concerns addressed with him. She advised that there was an opportunity for the Kitchen staff to ensure that the kitchen is thoroughly cleaned when scheduled. She stated that she had met with the Dietary Manager about ensuring that these concerns were corrected, and the staff was 675447 Page 7 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in-serviced on food storage, and cleaning the kitchen. She advised the risk of the concerns identified could result in food contamination, and residents getting ill. Record Review of the Facility's policy on Food Storage and Kitchen Sanitation dated 12/01/11, revealed All foods will be stored according to Federal and State guideline. All refrigerated food are labeled, dated, and tightly sealed. Scoops are stored covered in a protected area. Scoops are washed weekly or as needed. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, 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. Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. All equipment and utensils must be cleaned and sanitized. 675447 Page 8 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0825 Provide or get specialized rehabilitative services as required for a resident. 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 provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity as set forth at §483.120(c) for 2 of 5 residents (Resident #68 and #82) for residents observed for specialized rehabilitative services. Residents Affected - Few The facility failed to ensure Resident #68, and Resident #82 received their physical therapy evaluation and physical therapy. This failure placed residents at risk of having a decline in their activities for daily living. Findings include: Review of Resident #68's Face Sheet, dated 08/23/23, revealed she was a 60 -year-old female readmitted on [DATE]. Relevant diagnoses included Cardiac Arrect (heart attack), Respiratory Failure (difficulty breathing), and Depression. Review of Resident #68's MDS (Minimum Data Set), dated 07/27/2023 stated she was cognitively intact with a BIMS score of 15. Record review of Resident #68's active Physician orders dated 08/23/23 revealed, Physician orders dated 07/28/23 for PT (Physical Therapy) eval (evaluation) and treat as indicated. Interview on 08/22/23 at 10:41 AM with Resident #68 revealed, she expressed concerns about not receiving her therapy since she had been readmitted to the facility on [DATE]. She stated had mentioned this to staff but had not heard back from anyone. She advised that she wanted therapy so that she could improve in her condition so that she could go home. Review of Resident #82's Face Sheet, dated 08/23/23, revealed she was a 35 -year-old female admitted on [DATE]. Relevant diagnoses included Lack of Coordination, Weakness, and, and Depression. Review of Resident #82's MDS (Minimum Data Set), dated 05/19/2023 stated she was cognitively intact with a BIMS score of 15. Record review of Resident #82's active Physician orders dated 08/23/23 revealed, Physician orders dated 05/22/23 for Initial PT evaluation and treat diagnosis is completed. PT clarification order for 3x-5x a week for 12 weeks for therapeutic activities, neuro re-education and balance training to reduce falls. Interview on 08/22/23 at 10:41 AM with Resident #82 revealed, she expressed concerns about not receiving her therapy since she had been admitted to the facility. She stated had mentioned this to staff and spoke with the Therapy Director. She stated she was advised every time that she would be starting soon but she still had not. She stated that she thinks they may have thought she would just forget about it. 675447 Page 9 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Director of Therapy on 08/22/23 at 12:00 PM, revealed he was overall responsible for ensuring the residents had received their therapy. He stated that Resident #82 had not received her therapy because she was initially evaluated, and she did not appear to have the cognitive ability to follow commands. He was asked to provide a copy of the evaluation completed for this resident and he was not able to produce it. He was able to provide a psychiatric report from Senior Psychological Care Dallas, dated 06/05/23, indicating the resident's attention span and concentration was not good; however, a second psychiatric report from Senior Psychological Care Dallas, dated 06/25/23, indicated that the resident's c attention span and concentration had improved to fair. The Director of Therapy did not have any comments once he was presented with this information. The Director of Therapy stated that Resident #68 had not received her physical therapy because she was not ready for therapy, based on the therapy department's evaluation. He was asked to provide a copy of the evaluations completed for the resident and he produced an evaluation form dated 06/20/23, which indicated physical therapy not being recommended by the therapy department; however, the evaluation form was not completed, and the resident was not admitted at the date of the evaluation. The Director of therapy could not explain this concern. The Director of Therapy stated the risk of both residents not receiving therapy could result in a decline in their physical abilities. Interview with Assistant Administrator on 08/24/23 at 10:55 AM revealed, she had discussions with the Director of Therapy regarding the failure of Resident #68 and #82 not receiving their therapy. She stated she thinks the residents originally arrived to the facility with some cognitive concerns and may not had been ready cognitively to participate in any type of therapy, and they failed to properly re-evaluate the residents to determine if their cognitive status had improved. She stated she had met with the therapy department to create a plan to avoid this from occurring in the future. She stated a Therapy screening form was created, which involved daily screenings, conducted by the Therapy Director, for residents in possible need of Therapeutic services. She advised the risk of the residents not receiving the appropriate therapy could result in the resident having a decline in their health. She advised that both residents were evaluated and scheduled to start physical therapy the following week. Record review of the facility's policy on Therapy Screening and Evaluations, dated 01/2020, revealed Each facility will ensure that all residents are screened and/or evaluated routinely and as needed. This is required to assist in the prevention of declines and/or improve functional ability so that the resident maintains their highest practical well-being. 675447 Page 10 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #60, #63, #16, and #30) of residents observed for infection control. Residents Affected - Some The facility failed to ensure CMA C sanitized the blood pressure cuff between Resident #60, Resident #63, Resident #16, and Resident #30. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #60's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia and hemiparesis following cerebral infarction (interruption of blood flow to the brain), hyperlipidemia, essential (primary) hypertension. Review of Resident #60's Quarterly MDS dated [DATE] reflected that resident #60 was cognitively intact with a BIMS score of 15. Resident required limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. Resident also needed supervision for walk in corridor, locomotion in unit, eating, and bathing. The quarterly MDS also indicated stroke as the primary reason for admission and hypertension as one of the primary medical condition. Review of Resident #60's Comprehensive Care Plan dated 06/06/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #60 was taking lisinopril and carvedilol for hypertension. Review of Resident #60's Physician's order for lisinopril 10 mg dated 06/28/2023 reflected, Give 10 mg by mouth one time a day related to essential (primary) hypertension. Review of Resident #60's Physician's order for carvedilol 12.5 mg dated 08/08/2023 reflected, Give 1 tablet by mouth every 12 hours for HTN. Hold for SBP less than 100 or pulse less than 50. Review of Resident #63's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia, and vascular dementia. Review of Resident #63's Quarterly MDS dated [DATE] reflected that resident #63 was cognitively intact with a BIMS score of 15. Resident required supervision for bed mobility, transfer, walk in room, walk in corridor, locomotion in unit, locomotion off unit, eating, dressing, toilet use, and personal hygiene. The quarterly MDS also indicated hypertension as one of the primary medical condition. Review of Resident #63's Comprehensive Care Plan dated 08/14/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #63 was taking amlodipine. 675447 Page 11 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #63's Physician's order for amlodipine besylate 5 mg dated 12/27/2022 reflected, Give 1 tablet by mouth one time a day related to essential (primary) hypertension. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #16's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia (an excess of fat particles in the blood), and unspecified encephalopathy (broad term for any brain disease that alters brain function or structure). Review of Resident #16's Quarterly MDS dated [DATE] reflected that Resident #63 was cognitively intact with a BIMS score of 15. Resident required extensive assistance for bed mobility, transfer, locomotion in unit, dressing, toilet use, and personal hygiene. Supervision required for eating. The quarterly MDS also indicated hypertension as one of the primary medical condition. Review of Resident #16's Comprehensive Care Plan dated 08/16/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #16 was taking losartan, amlodipine, and clonidine H. Review of Resident #16's Physician's order for losartan potassium 100 mg dated 05/15/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #16's Physician's order for amlodipine besylate 10 mg dated 05/25/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Review of Resident #16's Physician's order for clonidine 0.1 mg dated 05/25/2023 reflected, Give 1 tablet by mouth every six hours as needed for HTN for systolic blood pressure greater than 170. Review of Resident #30's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia, and type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral. Review of Resident #30's Comprehensive MDS dated [DATE] reflected that resident #30 has severe impairment in cognition with a BIMS score of 07. Resident required supervision for bed mobility, transfer, walk in room, walk in corridor, locomotion in unit, locomotion off unit, dressing, eating, toilet use, bathing, and personal hygiene. The comprehensive MDS also indicated hypertension as one of the primary medical condition. Review of Resident #30's Comprehensive Care Plan dated 06/19/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #30 was taking lisinopril, amlodipine, and atenolol potassium. Review of Resident #30's Physician's order for lisinopril 20 mg dated 05/26/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #30's Physician's order for amlodipine 10 mg dated 05/26/2023 reflected, Give 1 675447 Page 12 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #30's Physician's order for atenolol 100 mg dated 05/26/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Observation on 08/23/2023 at 8:02 AM, revealed that CMA C picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized. CMA C placed the blood pressure cuff on Resident #60's arm. After the blood pressure reading was completed, CMA C went straight to Resident #63 and placed the blood pressure cuff on Resident #63's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart and then prepared and gave the medications to Residents #60 and then prepared and gave the medications to Resident #63. Observation on 08/23/2023 at 8:37 AM, revealed that CMA C picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized. CMA C placed the blood pressure cuff on Resident #16's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart. CMA C prepared and gave the medications to Resident #16. Observation on 08/23/2023 at 8:43 AM, revealed that CMA C picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized. CMA C placed the blood pressure cuff on Resident #30's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart. CMA C prepared and gave the medications to Resident #30. Interview with CMA C on 08/23/2023 at 10:34 AM, CMA C stated she had been with the facility for two years. She said that she obtained the blood pressure of the residents before giving the medication for hypertension. CMA C stated that she washes or sanitizes her hands before and after giving medications. When asked what should be done after using the blood pressure cuff. She replied that it should be cleaned with a sanitizing wipe. She then acknowledged that she forgot to sanitize the blood pressure cuff in between residents when she passed medications that morning. She stated that this action could cause infection to transfer from one resident to another. Interview with LVN A on 08/23/2023 at 10:44 AM, LVN A stated that he had been with the facility for a year. LVN A stated that the blood pressure cuff should be sanitized in between residents. If the blood pressure cuff was not sanitized, it could cause cross contaminations and infection control issues. Interview with ADON N on 08/23/2023 at 11:50 AM, ADON N stated that the blood pressure cuff should be sanitized after every use or after every resident. ADON N said that if the blood pressure cuff is not sanitized, it could cause cross contamination and infection to spread. ADON N said that the expectation was for the blood pressure cuff would be sanitized in between residents. Interview with the DON on 08/24/2023 at 8:43 AM, DON stated that ADON N made her aware of the infection control issues. DON stated that the blood pressure cuff should be sanitized every after use. She said that not sanitizing the blood pressure cuff could cause cross contamination or development of new infections. Interview with the Assistant Administrator on 08/24/2023 at 10:01 AM, Assistant Administrator stated that the expectation was for the staff to follow the policies and procedures of the facility in 675447 Page 13 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some general. She said the residents should feel safe and living to their full potential. The Assistant Administrator said that all staff should adhere to what is the best standard of care. Record review of facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment, Med-Pass Inc., rev. October 2018 revealed Policy Interpretation and Implementation . d. reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 675447 Page 14 of 15 675447 08/24/2023 The Highlands Guest Care Center 9009 Forest LN Dallas, TX 75243

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 5 resident rooms (Resident # 12) observed for a safe environment. The facility failed to ensure that Resident #12's room was free from any safety hazards by allowing the resident to have had a plugged-in surge protector located on the top of his bed. This failure placed residents at risk of a safety hazard, specifically an electrical fire, occurring within the facility and causing potential harm to the residents. Findings include: Observation and interview on 08/22/23 at 11:53 AM with Resident #12 revealed, Resident #12 lying in bed. He was observed to have a surge protector on the top of the bed, alongside him. The surge protector was observed to have approximately three electrical items plugged into it. He stated he had a lot of items that required electricity and had the surge protector for it. Interview with Environmental Service Director on 08/23/23 at 10:00 AM revealed, he was asked about the surge protector located on a resident's bed and he knew exactly the resident being referenced. He advised that he had addressed this with the resident and facility staff that this was not allowed and should be corrected anytime it was observed. He stated the risk of allowing the surge protector to be on the resident's bed could result in a fire and placing all residents at the facility at risk. Interview with Assistant Administrator on 08/24/23 at 10:55 AM revealed, the Environmental Service Director had made her aware of the concerns of Resident #12 having a surge protector on his bed. She stated that they continued to have this concern with the resident, and she had to constantly remind staff to correct this issue anytime it was observed, but she thinks that staff gets tired of always having to convince the resident of placing the surge protector on the floor as opposed to the bed. She stated she will in-service staff on checking for these types of safety hazards whenever they are in a resident's room, especially resident #12's room. She stated the risk of the resident having the surge protector on his bed could had resulted in a firm, which could harm the resident and other residents in the facility. Review of facility policy, Homelike Environment, 02/2021, revealed Policy Statement . Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation . 2. The facility staff and management maximizes . characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. 675447 Page 15 of 15