Health inspection·September 28, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 16 residents (Resident #23) reviewed for resident rights in that: Resident #23 was not served her meal timely with respect to residents sitting at the same table and was served 9 minutes later than other residents sitting at the same table. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record review of Resident #23's face sheet, dated 9/28/2023, reflected a [AGE] year-old resident most recently admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry). Record review of Resident #23's MDS Assessment, dated 9/28/2023, reflected a BIMS score of 99, which indicates the resident chose not to participate, or the resident gave a nonsensical response. Observation on 9/25/2023 at 12:40 PM revealed staff began to pass trays for lunch meal service. Observation on 9/25/2023 at 1:08 PM revealed residents at Resident #23's table had been served. Resident #23 was not served at this time. Observation and interview on 9/25/2023 at 1:16 PM revealed Resident #23 was fidgeting and looking at the food of the residents sitting at her table. When Resident #23 was asked if she was hungry, resident stated yes. When Resident #23 was asked if it upsets her to wait while the others at her table have food, the resident nodded yes. Observation and interview on 9/25/2023 at 1:17 PM, GVN B stated she was not sure where Resident #23's meal tray was, but that she would get it for her. Resident #23 was then observed being served by GVN B. Interview on 9/27/2023 at 1:57 PM, GVN B stated staff attempt to serve residents at the same table Page 1 of 5 675489 675489 09/28/2023 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0550 at the same time and was not sure why Resident #23 was not served appropriately. Level of Harm - Minimal harm or potential for actual harm Interview on 9/28/2023 at 1:41 PM, the Administrator stated that her expectation was for all residents to be served at the same time. Residents Affected - Few Record review of facility policy on dignity, undated, revealed residents are to be treated with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. 675489 Page 2 of 5 675489 09/28/2023 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan after each assessment for 1 (#12) out of 8 residents reviewed for comprehensive care plans in that: Resident #12's comprehensive care plan inaccurately reflected she had an indwelling urinary catheter. This deficient practice could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care. The findings included: Record review of Resident #12's electronic face sheet dated 09/28/2023 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy (condition in which the brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), type 2 diabetes mellitus (condition that affects how the body uses glucose, the main source of energy for cells), and hemiplegia (symptom that involves one-sided paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke happens when the blood supply to part of the brain is reduced or interrupted, preventing brain tissue from getting oxygen and nutrients). Record review of Resident #12's quarterly MDS assessment with an ARD of 08/26/2023 reflected she did not have an indwelling urinary catheter. Record review of Resident #12's comprehensive care plan revised on 07/10/2023 reflected Focus .I have an Indwelling Catheter .Interventions .Monitor and document output. Observation on 09/25/2023 at 10:40 a.m. of Resident #12 revealed she was sitting up in the sitting room in the facility and she did not have an indwelling urinary catheter. Interview on 09/28/2023 at 1:03 p.m. with LVN A, who completed the comprehensive care plan revealed that Resident #12's indwelling urinary catheter was removed on August 3, 2023, and her care plan needed to be revised. She stated revision and update of the comprehensive care plan was important because it reflected what care the resident required. Interview on 09/28/2023 at 2:00 p.m. with the DON revealed Resident #12's comprehensive person-centered care plan needed to be revised to reflect she no longer had an indwelling urinary catheter. She stated the comprehensive care plan was a communication tool to address what the resident needs were. Record review of the facility policy and procedure undated reflected The resident's care plan will be reviewed after each .MDS assessment, and revised based on changing goals, preferences and needs of the resident in response to current interventions. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, 675489 Page 3 of 5 675489 09/28/2023 Devine Health & Rehabilitation 104 Enterprise Ave Devine, TX 78016

F 0657 Level of Harm - Minimal harm or potential for actual harm Version 1.17.1, October 2019 revealed Care Plan Completion .the resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Residents Affected - Few 675489 Page 4 of 5 675489 09/28/2023 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the kitchen These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 9/25/2023 at 11:10 AM revealed a black substance build-up within the ice maker in the dining room. Interview on 9/25/2023 at 12:53 PM, the DM stated the kitchen and maintenance staff were both responsible for cleaning the ice maker. The DM stated the ice maker was cleaned weekly and deep cleaned monthly. The DM stated the ice maker should be cleaned and her expectation for it was to be cleaned properly and not have any black substance build-up within the ice maker. The DM stated she did not know there was black substance in the ice maker, and that it had been cleaned last week. The DM stated it was her responsibility to monitor kitchen cleanliness. Interview on 9/26/2023 at 12:35 PM, the Administrator stated her expectation is for the ice maker to be cleaned appropriately, and there should not be black substance in the ice maker. The Administrator confirmed the ice maker needed to be cleaned. The Administrator stated the risk to residents could include foodborne illness. Record review of the facility nutritional policy titled Cleaning of the Ice Machine, undated, reflected The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Record review of the facility ice maker cleaning log, undated, revealed the ice maker is on the task list for the facility maintenance department to clean monthly. This record did not indicate the last time the ice maker was cleaned. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. 675489 Page 5 of 5