Health inspection·September 8, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 resident (Residents #121) reviewed for care plans, in that: The facility failed to ensure Resident #121 Full code status was care planned. This deficient practice place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #121's face sheet, dated 09/08/2023, revealed the resident was admitted on [DATE] with diagnoses that included: chronic kidney disease, adult failure to thrive, and severe protein-calorie malnutrition. Record review of Resident #121's Quarterly MDS assessment, dated 08/01/2023, revealed the resident had a BIMS score of 15, which indicated intact cognition. Record review of Resident #121's care plan revealed care plan was initiated 08/09/2023. Further review revealed code status was not listed on the care plan. Record review of Resident #121's physician orders, dated 09/08/2023 revealed and order entered on 07/28/2023 that read AD: Full Code. During a record review and an interview on 09/08/2023 at 5:31 p.m., MDS Coordinator confirmed and stated Resident #121's code status was not listed on her care plan. She further stated the SW was responsible for a resident's code status. The MDS Coordinator believed there was no potential harm to the resident because the code status showed up on the top bar in the EHR. During a record review and an interview on 09/08/2023 at 5:42 p.m., the SW confirmed and stated there was not a code status on Resident #121's care plan. The SW stated she might have missed it because she was focused on the actual DNR's being completed accurately. The SW stated she was responsible for a resident's code status. The SW stated she believed there was no potential harm to the resident because it was updated in other areas like at the top bar in the resident's EHR and on the crash Page 1 of 12 675542 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0656 cart. The SW stated she updated the code status' weekly on the crash cart. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/08/2023 at 6:15 p.m., the DON stated the SW was responsible for resident's code status being completed on the care plans. The DON stated she believed there was not a potential harm to the resident because it was Resident #121's status bar in the EHR and it was updated periodically on the crash cart too. Residents Affected - Few During an interview on 09/08/2023 at 6:17 p.m., the ADMN stated the SW was responsible for resident's code status being completed on the care plans. The ADMN stated she believed there was not a potential harm to the resident because it was Resident #121's status bar in the EHR and it was updated periodically on the crash cart too. Record review of the facility policy titled Care Planning, undated, revealed, Policy: An activity related problem, goal and approach will be formulated for residents who have an activity problem, need or strength within seven (7) days of move-in, quarterly, and as needed, corresponding with the care plan conference date. Activities shall have active approaches on other care plans throughout the comprehensive care plan for each resident. 675542 Page 2 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

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. Based on observation, interview, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs, in that: The facility failed to ensure the pureed mashed potatoes and pureed chicken cutlet was a pudding consistency as required for food served to residents who received a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of posted menu, dated 09/06/2023, revealed the menu for the lunch service was Chicken Cutlet with pasta, and Garlic Mashed Potatoes [ .] During an observation and interview on 09/06/2023 beginning at 11:07 a.m., revealed the pureed chicken cutlet was too thick in the serving dish after [NAME] Q had just made it. [NAME] R walked over to [NAME] Q and instructed her to puree the chicken more consistently. The DM stated she was told the pureed items were supposed to be the consistency of mashed potatoes. The DM further stated the previous DM was who told her this. During an observation of test tray on 09/06/2023 beginning at 1:20 p.m., the test tray included the regular textured menu items and the pureed menu items. The regular and pureed Garlic mashed potatoes were the same, which included the potato skins. The pureed Chicken Cutlet still had undetermined small pieces or lumps throughout the pureed chicken. During an observation and interview on 09/06/2023 at 2:58 p.m., the DM stated the pureed Garlic mashed potatoes were not a pudding texture because of the potato skins that were included. The DM looked through the pureed Chicken Cutlet but was not able to state it still had lumps in it and was unable to taste test it because she was currently not feeling well. The DM stated the potential harm to residents was aspiration. During an interview on 09/08/2023 at 06:18 p.m., the DON stated the cook and DM were responsible for ensuring the pureed items were a pudding consistency. She stated the potential harm to residents was chocking. During an interview on 09/08/2023 at 6:22 p.m., The ADMN stated the DM was responsible for the kitchen area. He stated the potential harm to residents was the possibility of chocking. Record review of facility policy titled, Mechanically Altered Diets, undated, revealed Purpose: To provide safely prepared mechanically altered meals per IDDS [International Dysphagia Diet Standard]. [ .] 7. Pureed/Extremely Thick (#4): Should be cooked to the same standard as our regular textured foods. Usually eaten with a spoon. Cannot drink from cup. Cannot be sucked through a straw. Does not require chewing. Can be piped, layered or molded. Falls off spoon in a single spoonful when tilted. No lumps. Not sticky. Liquid must be separated. No biting or chewing is required. 8. Testing for Pureed/Extremely Thick[:] Fork Pressure: the prongs of a fork can make a clear pattern on the 675542 Page 3 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0805 surface/no lumps. Fork Drip Test: Sample sits in a mound/pile above the fork with small tail. Should not be firm or sticky. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675542 Page 4 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

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 (Main Kitchen), in that: 1. The facility failed to ensure an items in the walk-in refrigerator and dry storage areas were dated and or discarded correctly 2. The facility failed to ensure equipment used to cook were properly and thoroughly cleaned. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: 1. During an observation and interview on 09/06/2023 beginning at 11:21 a.m., revealed in the walk-in refrigerator a 5 lb. bag of opened mozzarella with no received or opened date; two each of 1 lb. butter with no received date; five each of 1 lb. [brand name] sliced Monterey jack cheese with no received dates; three each of 5 lb. shredded mild cheddar cheese with no received date; a 5 lb. shredded Monterey [NAME] cheese with no received date, seven each of 1 lb. [brand name] mozzarella cheese with no received date and a 1 lb. bag of opened parmesan with no received or opened date. The DM stated some of the items came from the truck yesterday and these items were supposed to be dated after it was delivered. During an observation and interview on 09/06/2023 beginning at 11:38 a.m., revealed in the dry storage area an opened package of six English muffins were not dated with a received date or opened date; two opened packages of Marble Rye Sourdough bread with a date of 09/01/2023 and unable to determine if this was an opened date or the received date; one opened package of wheat bread that had mold on one of the slices. The DM stated some of the items came from the truck yesterday and these items were supposed to be dated after it was delivered. 2. During an observation and interview on 09/06/2023 at 11:23 a.m., revealed there was a dirty grill on both sides with caked and burnt food particles still on it. The DM stated it was not in a long while and was unable to recall how long ago it was used. Further observation revealed the sides and front of the fryer unit and the oven/stove/flat top grill were dirty food particles and or running grease. The DM stated it should have been cleaned. The DM was unable to recall the last time the kitchen was deep cleaned but stated it was deep cleaned monthly. During an interview on 09/06/2023 at 2:58 p.m., the DM stated the potential harm to residents by not having cooking equipment cleaned was cross contamination. The DM further stated the potential harm to residents by items in the refrigerator and storage areas were knowing if the items were healthy enough to serve. During an interview on 09/08/2023 at 06:18 p.m., the DON the DM was responsible for ensuring the kitchen was cleaned and or items were dated correctly. The DON further stated the potential harm to residents was infection control. 675542 Page 5 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 09/08/2023 at 06:22 p.m., the ADMN stated the DM was responsible for the kitchen area. He further stated yes there was a potential to harm to residents for minimal harm. Record review of facility policy titled Labeling and Dating of Food, undated, revealed purpose: To provide procedures to properly store food that is made in house, ordered in from approved vender. Procedure: 1. All food removed from original package must have product name, receive date and use by date. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready -to-Eat, Time/Temperature Control for Safety Food, Date Marking. (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 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; 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. 675542 Page 6 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish and 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 infection for 1 of 2 isolation rooms and 3 of 7 residents (Resident #4, #78 and, #130) reviewed for infection control, in that: Residents Affected - Some 1. Resident #4's room had personal protective equipment on the door but no sign to indicate the type of isolation the resident was under. 2. CNA B failed to wash or sanitize her hands or change her gloves after touching the privacy curtain and before starting perineal care. 3. RN C failed to wash or sanitize her hands and change gloves after cleaning a wound. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #4's face sheet, dated 09/07/2023, revealed an admission date of 02/23/2023 and, a readmission date of 07/22/2023, with diagnoses which included: Hypertension(High blood pressure), Chronic obstructive pulmonary disease(progressive lung disease characterized by airflow limitation), Dementia(decline in cognitive abilities) and, Urinary tract infection(an infection in any part of the urinary system) Record review of Resident #4's physician orders, dated 07/09/2023, revealed an order for, Contact Isolation for VRE in the urine every shift (VRE- vancomycin resistant enterococci, an antibiotic resistant infection). Observation on 09/05/23 at 11:20 a.m. of Resident #4's door revealed personal protective equipment was on the door but there was no signage revealing the type of isolation the resident was under or the equipment to use was seen. During an interview with LVN A on 09/05/2023 at 11:49 a.m., LVN A confirmed Resident #4 was on contact isolation and confirmed the signs indicating isolation and the type of isolation were missing and should have been on the door. LVN A asked if she could go get the signs and place them on the door. LVN A stated she did not know why the signs were missing. During an interview with the DON on 09/08/2023 at 4:30 p.m., the DON confirmed the signs should have been at the door to indicate the type of isolation and informed staff and visitor. The DON stated there was a risk somebody would enter the room without wearing the appropriate protective equipment, and further stated the ADON was in charge to place the signs on isolation room and if she was on leave the charge nurse for the resident was in charge of placing the signage on the doors. Record review of the facility policy, titled Isolation notices, undated, revealed Appropriate color-coded isolation notices will be used to alert associates of the implementation of isolation precautions, while protecting the privacy of the resident. When isolation precautions are implemented, an 675542 Page 7 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some appropriate isolation sign that states Visitors: please report to the wellness station before entering printed on it, will be placed at the entrance/doorway of the resident's room. 2. Record review of Resident #78's face sheet, dated 09/08/2023, revealed an admission date of 04/12/2019 and, a readmission date of 08/19/2023, with diagnoses which included: Multiple myeloma (type of cancer), Type 2 diabetes mellitus(high level of sugar in the blood), Hypertension(High blood pressure) and, Fatty liver(excess fat build up in the liver) Record review of Resident #78's admission MDS assessment, dated 08/22/2023, revealed the resident had a BIMS score of 15, indicating no cognitive impairment and, the resident required extensive assistance. Resident #78 was coded as having an indwelling catheter and frequently incontinent of bowel. Observation on 09/07/23 at 11:51 a.m. revealed while providing incontinent care and catheter care for Resident # 78, CNA B, after washing her hands, touched the privacy curtain with her bare hands to close it. CNA B then, put her gloves on without sanitizing or washing her hands and started providing care for the resident. During an interview with CNA B, on 09/07/2023 at 12:00 p.m., CNA B confirmed she touched the privacy curtain with her bare hands after washing her hands and did not sanitize or wash again before putting her gloves on and starting care. CNA B stated she did not realize the privacy curtain was considered to be dirty and asked what she should have done differently. CNA B confirmed receiving infection training within the current year. Review of peri care check off for CNA B revealed she had passed her check off on 08/11/2023. During an interview with the DON on 09/07/2023 at 4:30 p.m., the DON confirmed the CNA should have sanitized her hands after touching the privacy curtain and prior to put her gloves on and start care. The DON confirmed infection control training was provided to the staff. The DON stated The ADON was in charge to provide the training to the staff and,The DON and ADON would spot check the skills of the staff. Review of facility policy titled hand washing/hand hygiene, undated, revealed Associate will wash their hands after contact with furnishing or medical equipment in immediate vicinity of resident 3. Record review of Resident #130's face sheet, dated 09/08/2023, revealed an admission date of 08/18/2023 with diagnoses which included: Cellulitis(skin infection), Chronic kidney disease (gradual loss of kidney function), Non-Hodgkin lymphoma (blood cancer). Record review of Resident #130's admission MDS assessment, dated 08/22/2023, revealed the resident had a BIMS score of 15, indicating no cognitive impairment and, the resident required extensive assistance. Resident #130 was coded as being frequently incontinent of bowel and bladder. Observation on 09/07/23 01:47 p.m., revealed while providing wound care for Resident #130, RN C, after cleaning the resident's wounds, did not change her gloves or wash or sanitize her hands. RN C then applied treatment and the new dressing. During an interview with RN C, on 09/07/2023 at 2:11 p.m., RN C confirmed she washed her hands 675542 Page 8 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after removing the dressing but not after washing the wounds and prior to apply treatment and place new dressings. RN C confirmed she should have changed her gloves and wash her hands after cleaning the wounds to prevent re-contamination of the clean wound. RN C stated she forgot to change her gloves. RN C confirmed receiving infection control within the year. Review of Wellness nurse competency appraisal for RN C revealed she had passed competency on infection control on 05/05/2023. During an interview with the DON on 09/07/2023 at 4:30 p.m., the DON confirmed the nurse should have change gloves and wash her hands after cleaning the wound to prevent re-contamination of the wound. The DON confirmed infection control training was provided to the staff. The DON stated The ADON was in charge to provide the training to the staff and, The DON and ADON would spot check the skills of the staff. Review of facility policy titled hand washing/hand hygiene, undated, revealed Associate will wash their hands any time hands have possibly become contaminated 675542 Page 9 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 shower room observed for environment, in that: Residents Affected - Some The facility failed to ensure potential hazards were locked up in the shower room. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: Observation on 09/05/23 11:00 a.m. revealed the shower room's door was open. A closet seen in the room had a lock but the lock was opened as well. Inside the closet, two bottle of peroxide multi surface cleanser and disinfectant were observed. The bottles had precautionary statements hazards to humans and domestic animals on them. During an interview on 09/05/2023 at 11:05 a.m. with the DON, she confirmed the bottles were in the closet and both the closet and room's doors were open. The DON confirmed the bottles had precautionary statement and confirmed she had residents with dementia who self propel who could be put at risk by accessing the bottles. The DON did not know who had left the door open or why it was left open. Review of facility policy, titled Safety requirements, undated, revealed Chemicals (detergents, softeners, and stain removers) will be stored in a locked area. 675542 Page 10 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 5 of 18 employees (CNA E, CNA F, CNA H, CNA J, LVN K, and RN M) reviewed for training, in that: The facility failed to ensure CNA E, CNA F, CNA H, CNA J, LVN K, and RN M completed QAPI training within the last year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: 1. Record review of Staff Roster, undated, revealed CNA F was hired on 12/14/2021 Record review of CNA F's training history revealed CNA F had not completed QAPI training in the last year. 2. Record review of Staff Roster, undated, revealed the CNA H was hired on 01/18/2022 Record review of CNA H's training history revealed CNA H had not completed QAPI training in the last year. 3. Record review of Staff Roster, undated, revealed CNA J was hired on 12/28/2021 Record review of CNA J's training history revealed CNA J had not completed QAPI training in the last year. 4. Record review of Staff Roster, undated, revealed LVN K was hired on 01/18/2018 Record review of LVN K's training history revealed LVN K had not completed QAPI training in the last year. 5. Record review of Staff Roster, undated, revealed RN M was hired on 11/08/2017 Record review of RN M's staff records revealed RN M had not completed QAPI training in the last year. During an interview on 09/08/2023 at 5:04 p.m., HR stated he was not aware that all staff needed QAPI training. He stated he was responsible for ensuring staff completed all the required training. HR stated the potential harm to residents was quality of life. During an interview on 09/08/2023 at 6:15 p.m., the DON stated it was a team effort but that she was ultimately responsible for all required training to be completed. The DON stated the potential harm to residents was staff skills not being proficient. 675542 Page 11 of 12 675542 09/08/2023 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 09/08/2023 at 6:17 p.m., the ADMN stated it was a team effort but that the DON was ultimately responsible for all required training to be completed. The ADMN stated the potential harm to residents was staff skills not being proficient. Record review of facility policy titled Training and Competency Documentation, undated, revealed To ensure the appropriate records are kept to ensure proper documentation of all training and competency skills. 675542 Page 12 of 12