Health inspection·August 5, 2022

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review; the facility failed to ensure the food was prepared by methods that conserve nutritive value and appearance for 1 of 1 Facility. Residents Affected - Few The facility failed to maintain the nutritive value of the pureed meal for residents by mixing the bread and beef as a single meal item. This failure could place all residents who ate pureed meals prepared from the kitchen at risk of loss of nutritive value and protein. The findings included: In an observation on 08/03/2022 at 12:56 PM, [NAME] A provided a pureed meal to servers in the kitchen without a bread slice as documented on the meal ticket. The meal ticket indicated pureed meatloaf . pureed bread as individual line items. In an interview on 08/03/2022 at 12:57 PM, [NAME] A stated the pureed meals were not being provided with bread slices as she had pureed the meatloaf with slices of bread in order to serve the food as a single item. [NAME] A stated she understood this to be acceptable being that both items were used and provided to the residents. In an interview on 08/03/2022 at 3:11 PM, the facility Dietitian consult stated that Cooks were not to mix items for pureed meals as that would potentially reduce the nutritive value and potentially reduce protein. The Dietitian stated that she has completed an in-service with all Cooks in the kitchen on pureeing meals. The Dietitian stated that [NAME] A was trained on pureeing meals but mixed the items and served them due to being nervous during the meal observation by the surveyor. In an interview on 08/03/2022 at 3:42 PM, the Dietary Manager stated that she trained dietary staff to prepare pureed meals to maintain nutritive value. The Dietary Manager stated she oversees the kitchen for pureeing but is always not present in the kitchen as her office is across the facility. The Dietary Manager stated she reviewed an in-service completed by the Dietitian with all Cooks that addressed pureeing meals for residents to maintain nutritive value and not mixing items without following proper dietary policy. The Dietary Manager stated this likely was due to [NAME] A being nervous while being observed by a surveyor. The Dietary Manager stated the risk associated with mixing items intended for pureed meals and providing them as a single food item has the potential for reducing the nutritive value and thus reducing the protein intake. Record review of the facility's policy titled, Dietary Policy undated, revealed, meals prepared for residents must maintain nutritive value regardless of mechanicalizing or pureeing method . Page 1 of 7 675489 675489 08/05/2022 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

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 provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 1 of 1 meal (Lunch meal) reviewed, in that: During the lunch meal on 08/03/20202 temperature logs were not completed prior to serving. This failure could place residents at risk for unpalatable food temperature. The findings included: Observation on 08/03/2022 between 12:16 PM and 12:58 PM revealed [NAME] A completed lunch service in providing all meals and did not complete a temperature evaluation or documentation of the temperatures prior to serving. In an interview with [NAME] A on 08/03/2022 at 12:59 PM, [NAME] A stated she completed temperature checks during cooking to ensure proper temperatures were reached and then immediately logged into the temperature logbook. [NAME] A stated she completed an additional temperature check once the food was on the steam table and about to be served to ensure the foods were maintained to palatable temperatures. [NAME] A stated she will sometimes forget to check the temperatures after the food has been cooked and on the steam table and will document the temperatures at a later time. [NAME] A stated that she will log temperatures sometimes hours later after the meal has ended and she has time. [NAME] A stated the risk associated with not completing temperature checks and logs were that the food may not be at palatable temperatures and then cannot be audited after. [NAME] A stated she was trained by a previous Dietary Manager and was currently supervised by the current Dietary Manager. In an interview on 08/03/2022 at 2:30 PM, the Dietary Manager stated she supervises [NAME] A and that each kitchen shift always consists of a single [NAME] and a single Dietary Aide. The Dietary Manager stated the [NAME] was responsible for completing temperature evaluations of each food item during a meal and then logging them into the temperature logbook. The Dietary Manager stated that Cooks were required to immediately log each temperature once it was assessed. The Dietary Manager stated that the temperatures should be captured once they are in the oven cooking, and again 30 minutes prior to being served. The Dietary Manager stated the risk associated with not completing a temperature evaluation and logging the temperature would be a risk for not serving food at palatable temperatures. In an interview on 08/03/2022 at 3:45 PM, [NAME] A stated that she incorrectly mixed two items for pureed residents to consume and made this error due to being nervous of a surveyor observing her work. Record review of temperature log book, titled Temperature Logs, undated, revealed temperature categories for During Cooking and Prior to Serving columns. On day of review, 08/03/2022, column for Prior to Serving was found empty. Record review of the facility's policy titled, Dietary Policy undated, revealed, temperatures are to be logged throughout the preparation process . during [cooking] and additionally prior to serving. 675489 Page 2 of 7 675489 08/05/2022 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 (Resident #30) reviewed for incontinent care, in that: Residents Affected - Few CNA A did not use proper technique when cleaning Resident #30's rectal area during incontinent care. This deficient practice could place residents at risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #30's face sheet, dated 8/4/22, revealed an [AGE] year old with diagnoses that included urinary tract infection, diabetes, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dementia, hyperlipidemia (high cholesterol), major depressive disorder and hypertension (high blood pressure) Record review of Resident #30's most recent quarterly MDS assessment, dated 7/12/22 revealed a BIMS score of 11 which indicated the resident was moderately cognitively impaired for daily decision-making skills, was continent of bladder and frequently incontinent of bowel. Record review of Resident #30's care plan, revision date 5/27/22 revealed the resident was incontinent with interventions that included incontinent care frequently throughout the day and as requested/required. Observation and interview on 8/4/22 at 9:09 a.m., CNA A, assisted by Med Aide F, completed incontinent care on Resident #30 by wiping the resident's rectal area with one wipe. CNA A then took a clean incontinent brief and fastened the brief on the resident. CNA A stated to the Surveyor she had completed incontinent care on Resident #30. The Surveyor asked CNA A to unfasten Resident #30's clean brief and upon inspection, CNA A confirmed she had not used proper technique when cleaning Resident #30's rectal area. Resident #30 was noted with stool around the rectal area and a nickel size smudge of stool was noted on the resident's left upper inner thigh. CNA A required 1 wipe to clean the nickel size smudge of stool on the resident's left upper inner thigh and 3 additional wipes to remove the stool around the resident's rectal area. During an interview on 8/4/22 at 9:22 a.m., CNA A stated she did not use proper technique when cleaning Resident #30's rectal area because it was clear the resident still had stool on her. CNA A stated she was nervous. CNA A stated she had received competency training on incontinent care but could not recall when. CNA A stated, not using proper technique when providing incontinent care could result in the resident developing an infection, such as a urinary tract infection or skin infection. During an interview on 8/4/22 at 9:27 a.m., Medication Aide F stated she was aware Resident #30 still had visible stool around the rectal area and had also noted the smudge of stool on the resident's thigh. Medication Aide F stated, leaving stool on the resident's rectal area and on the thigh could result in the resident developing a urinary tract infection or skin breakdown. 675489 Page 3 of 7 675489 08/05/2022 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/4/22 at 1:15 p.m., the DON stated, it was the expectation of the CNA to ensure there was no stool left on the resident after incontinent care because it could cause skin irritation, skin breakdown or possibly a urinary tract infection. The DON stated she was responsible for in-services and competency training on incontinent care. Record review of the facility document titled, Skills Proficiency - Incontinent Care, dated 2/10/22 revealed CNA A had successfully completed the required in-service training to properly perform incontinent care. Further review of the document revealed in part, cleanse the rectal area thoroughly, including .the anus and the buttocks and hips . 675489 Page 4 of 7 675489 08/05/2022 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment, including emergency equipment in safe operating condition for 1 of 1 facility in that: Residents Affected - Many The facility did not maintain the Automatic External Defibrillator (AED; used to help those experiencing sudden cardiac arrest by analyzing the heart's rhythm and if necessary, deliver an electrical shock/defibrillation to help the heart re-establish an effective rhythm) in working condition at all times. These failure could place residents at-risk for not receiving treatment and care to meet their needs and preferences. The findings were: Record review of the product user manual for the Defibtech DDU-100 Semi-Automatic External Defibrillator, undated, revealed the following: - Section 1.1 Overview. Defibrillation and AED operating power is supplied by a replaceable (non-rechargeable) lithium battery pack that provides for long standby life and low maintenance operation. Battery packs are available in several configurations optimized for use in specific applications. Each pack is marked with an 'install by' or expiration date. -Section 1.2 K. Active Status Indicator (ASI). When the unit is off, this indicator blinks green to indicate the unit is fully operational and blinks red to indicate unit needs attention from the user or servicing. - Section 3.4 Installing and Removing the Battery Pack. A green Active Status Indicator on the label side of the battery pack will blink periodically to indicate that the battery pack is ready for use. If the status indicator is not blinking, either the 9V status battery has discharged of the battery pack is not suitable for use. If the indicator does not blink after a new 9V batter has been installed, the Battery pack should no longer be used and should be removed from service. When the battery pack is in the AED, a beep will provide notice that the 9V battery's capacity is low and that the 9V battery should be replaced. Within moments of insertion (if a non-discharged 9V ASI battery is installed) the DDU-100 will turn on and run a battery pack insertion self-check. The unit will automatically shut off after the test is run. Afterwards, the Active Status Indicator on the top corner of the DDU-100 AED will periodically flash (if a nondischarged 9V ASI battery was previously installed in the battery pack). If the indicator flashes green, the AED and battery pack are functioning properly, if the indicator flashes red, there is a problem. Record review of the facility Defibtech DDU-100 Operator Checklist for [DATE] revealed the following: Daily. Check the Active Status Indicator. Is it flashing green? Yes or No. Date of battery pack expiration [DATE]. Further review indicated the checklist was marked No, needs 9V battery on [DATE] and [DATE]. Record review of the facility Defibtech DDU-100 Operator Checklist for [DATE] revealed the 675489 Page 5 of 7 675489 08/05/2022 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0908 following: Level of Harm - Minimal harm or potential for actual harm Daily. Check the Active Status Indicator. Is it flashing green? Yes or No. Date of battery pack expiration [DATE]. Further review indicated the checklist was marked No on [DATE], [DATE] through [DATE] and [DATE] through [DATE]. Residents Affected - Many Record review of the facility Defibtech DDU-100 Operator Checklist for [DATE] revealed the following: Daily. Check the Active Status Indicator. Is it flashing green? Yes or No. Date of battery pack expiration [DATE]. Further review indicated the checklist was marked Yes on [DATE]. Record review of the facility resident roster, dated [DATE] revealed there were 14 residents who identified as FULL CODE status, indicating those residents requested CPR (cardiopulmonary resuscitation). Observation on [DATE] at 1:33 p.m. revealed the AED defibrillator mounted on a wall across from the nurse's station displayed a red blinking light. Observation on [DATE] at 4:35 p.m. revealed the AED defibrillator had been removed from where it had been mounted across from the nurse's station. Observation and interview on [DATE] at 4:41 p.m. revealed Medical Records Clerk C, who also identified herself as the Supplies Clerk, had disassembled the AED defibrillator on a desk in the DON's office. Medical Records Clerk C stated, the battery pack on the AED defibrillator was removed and a new 9V battery had been installed but the AED defibrillator was showing an error code. Medical Records Clerk C stated a staff had been instructed to go the store and obtain a new 9V battery. Medical Records Clerk C confirmed the facility had only 1 AED defibrillator. During an interview on [DATE] at 4:42 p.m., the Regional Nurse stated she had observed the AED defibrillator mounted on the wall across from the nurse's station had a solid red light which indicated the AED defibrillator was not operable and needed to be inspected. The Regional Nurse further stated, if the AED defibrillator was flashing a green light that meant the AED defibrillator was operable. The Regional Nurse confirmed the facility had only 1 AED defibrillator. During an observation and interview on [DATE] at 8:26 a.m., the DON stated a new AED defibrillator was acquired during the evening of [DATE] because the previous AED defibrillator was inoperable. The DON confirmed the facility had only one AED defibrillator. The DON stated if there was a problem with the AED defibrillator sometimes the staff would tell me about it, but not always. The DON stated she personally collected and reviewed the Defibtech DDU-100 Operator Checklist monthly. The DON stated, if the AED defibrillator light indicator flashed a red light that meant the AED defibrillator was inoperable. The DON reviewed the Defibtech DDU-100 Operator Checklist for [DATE] and stated she had worked on [DATE] and had marked no on the checklist indicating she was aware the AED defibrillator was inoperable. The DON stated, at that point I should have replaced the battery, didn't do it, don't know why, I don't remember. The DON stated, if a resident coded (refers to cardiac arrest; sudden unexpected loss of heart function, breathing and consciousness) and the AED defibrillator needed to be used and was inoperable the resident could die. Interview on [DATE] at 9:52 a.m., LVN E stated she had received CPR certification and completed 675489 Page 6 of 7 675489 08/05/2022 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many competency training on the use of the AED defibrillator. LVN E stated, if the AED defibrillator displayed a flashing or solid red light it meant something was wrong with the defibrillator and notify the DON. Interview on [DATE] at 10:00 a.m., Medication Aide F stated she had received CPR certification and had completed competency training on the use of the AED defibrillator. Medication Aide F stated, if the AED was flashing red or if the light was solid red it means the battery is low, it does make a noise, I think. I've never looked at that or watched to see that there's a red light. Not sure if the flashing red light or solid red light meant the AED machine wasn't working. Interview on [DATE] at 10:09 a.m., LVN B stated she had received CPR certification and had completed competency training on the use of the AED defibrillator. LVN B stated, if the AED defibrillator flashed a red blinking light it indicated the AED defibrillator had an operational malfunction, typically the battery pack. LVN B further stated, the flashing red light on the AED defibrillator meant it was not working and you could not use it because it was malfunctioning. During a telephone interview on [DATE] at 12:56 p.m., RN D stated the facility had only one AED that I know of. RN D stated she had worked on [DATE] and marked No and needs battery on the Defibtech DDU-100 Operator Checklist for [DATE]. RN D stated she had informed the DON the AED defibrillator had a low battery and had replaced the 9V battery, but the AED defibrillator did not flash a green light which would have indicated the AED defibrillator was operable. RN D stated she was not aware the AED defibrillator had a battery pack. RN D stated she was trained on the use of the AED from working at the hospital but not by the facility. The facility did not provide documentation on staff competency training on the use of the AED defibrillator at the time of the exit on [DATE]. 675489 Page 7 of 7