Health inspection·October 11, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 5 of 12 residents (Residents #15, #18, #5, #1, and #20) whose assessments were reviewed, in that: Residents Affected - Some 1. Resident #15 had falls on 8/30/2024 and 9/5/2024 but Resident #15's Quarterly MDS dated [DATE] revealed falls after admission was not coded for falls after admissioon or readmission. 2. Resident #18 had been using oxygen per nasal canula at 2 liters continuously since admission, but the admission MDS dated [DATE] was not coded for oxygen use. 3. Resident #5 had a fall on 9/8/2021 but Resident #5's QMDS dated [DATE] revealed falls after admission was not coded for falls after admission or readmission. 4. Resident #1 had been receiving hospice care since 11/30/2022, but Resident #1's quarterly MDS, dated [DATE], indicated regarding the question of if or not resident was receiving hospice care, the answer was marked as no. 5. Resident #20 had deep tissue injury to his left heel, but Resident #20's admission MDS, dated [DATE], indicated the resident did not have any deep tissue injury. This failure could place residents at-risk for inadequate care and services due to inaccurate MDS assessment. The findings included: 1.Record review of Resident #15's face sheet revealed the resident was a [AGE] year-old male with an admission date of 06/21/2023 and readmitted on [DATE] with diagnoses that included: abdominal aortic aneurysm (enlargement of the aorta), muscle weakness, traumatic subdural hemorrhage (blood clot that forms in the brain after an injury) with out loss of consciousness. Record review of Resident #15's Quarterly MDS 9/20/2024 revealed the resident had a BIMS score of 4. Resident #15 had falls on 08/30/2024 and 09/05/2024 per Care Plan dated 10/8/2024 that were not reflected on the Quarterly MDS. Record review of Resident #15's Care Plan dated 10/8/2024 revealed falls dated 08/30/2024 and 09/05/2024 that were care planned with interventions. Page 1 of 17 675542 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #18's face sheet revealed the resident was a [AGE] year-old female with an admission date of 4/22/2024 and readmitted [DATE] with diagnoses that included: acute pulmonary edema (build up of fluid in the lungs), prosthetic left knee joint ( knee joint replacement), and hypertension (high blood pressure). Record review of Resident #18's admission MDS dated [DATE] revealed the resident had a BIMS score of 13. Resident #18 had an order for oxygen on admission, per physician orders, but was not reflected on the admission MDS. Record review of Resident 18's Care Plan dated 9/30/2024 revealed oxygen therapy was care planned with interventions. 3.Record review of Resident #5's face sheet revealed the resident was a [AGE] year-old female with an admission date 1/18/2018 and was readmitted [DATE] with diagnoses that included: hypothyroidism (thyroid gland does not produce enough thyroid hormone), aphasia (disorder that affects a person's ability to understand or understand written or spoken language), muscle weakness. Record review of Resident #5's Quarterly MDS dated [DATE] revealed the resident had a BIMS score that was not obtainable. Resident #5 had a fall on 09/08/2021 per Care Plan dated 8/10/2024 that was not reflected on the Quarterly MDS. Record review of Resident #5's Care Plan dated 8/10/2024 revealed a fall on 09/08/2021 that was care planned with interventions in place. Interview on 10/10/2024 at 3:45PM MDS nurse LVN-B stated she acknowledged Resident #18's admission MDS dated [DATE] was inaccurate for the oxygen therapy not coded and that it did not affect the resident because Resident #18 received the oxygen per physician orders. LVN B stated the purpose of the MDS is for financial reimbursement. LVN B agreed the MDS and the Care Plan should reflect each other. Interview on 10/10/2024 at 3:54PM the Administrator stated the MDS should be correct and accurate because it explained the correct care that should be provided as well as financial reimbursements for the facility. The Administrator agreed the Care Plan and the MDS should have the same information. Interview on 10/10/2024 at 3:57PM the DON stated the MDS should be accurately coded to reflect the residents' needs and the care needed to provide, that it should match the residents' needs-the MDS drives the CP. The DON reviewed the MDS for Resident #15 for falls that was not coded on the MDS and acknowledged the error for falls not coded. The DON reviewed Resident #5's MDS for falls was not coded and agreed with the error and stated the fall should have been coded. The DON also reviewed the MDS for Resident #18 for oxygen not coded and acknowledged the error. The DON agreed the MDS, and the CP should match one another. 4. Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring seizures), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). 675542 Page 2 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's hospice informed consent, dated 11/29/2022, revealed the resident started receiving hospice care on 11/30/2022. Record review of Resident #1's care plan, dated revised 06/13/2023, revealed the resident had the care plan of 11-30-2022, the resident was admitted to hospice care services; intervention - consult with physician and social services to have hospice care for resident in the facility and contact [hospice care company] before any x-ray for any change in conditions, transfer, or death. Record review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS score was 9 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #1's quarterly MDS, dated [DATE], indicated the question of Hospice care in the Section 0 (Special Treatments and Program) was answered No. Interview on 10/09/2024 at 9:36 a.m. with LVN-A stated Resident #1 had been receiving hospice care since 11/30/2022. Interview on 10/11/2024 at 9:06 a.m. with MDS nurse LVN-B acknowledged Resident #1's quarterly MDS, dated [DATE], was inaccurate regarding the resident's hospice in the Section 0 (Special Treatments and Program) because the resident had been receiving hospice care since 11/30/2022. The question of Hospice care should had been answered Yes. Further interview with the MDS nurse LVN-B stated she did not know what reason she answered inaccurately to the resident quarterly MDS. Interview on 10/11/2024 at 9:14 a.m. with DON acknowledged Resident #1's quarterly MDS, dated [DATE], was inaccurate. It should had been answered Yes because the resident had been receiving hospice care since 11/30/2022. The potential harm was inaccurate MDS might affect inaccurate plan of care, and staff could provide inaccurate care to Resident #1. 5. Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and re-admitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing of the spinal canal). Record review of Resident #20's care plan, dated initiated 08/21/2024, revealed Resident #20 had pressure injury to sacrum and left heel. For intervention, administering treatments as ordered and monitor for effectiveness. Record review of Resident #20's physician order, dated 09/30/2024, revealed the resident had the order of Wound care to left heel - cleanse with normal saline, pat dry, apply skin prep to peri-wound, then apply nickel thick Santyl ointment to wound bed, then calcium alginate, and cover with dry dressing every day and as needed. Record review of Resident #20's admission MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflecting he had moderate cognitive impairment. Further record review of Resident #20's admission MDS, dated [DATE], indicated the question of number of unstageable pressure injuries presenting as deep tissue injury in the Section M (Skin Conditions) was answered 0. Observation on 10/10/2024 at 12:12 p.m. revealed wound care nurse RN-C provided wound care as 675542 Page 3 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0641 Level of Harm - Minimal harm or potential for actual harm ordered to Resident #20. There were two pressure injuries. One was sacrum area (buttock area), and the other was left heel. Interview on 10/10/2024 at 12:12 p.m. with wound care nurse RN-C acknowledged Resident #20 had pressure injury presenting as deep tissue injury to the resident's left heel. Residents Affected - Some Interview on 10/10/2024 at 3:42 p.m. with MDS nurse LVN-B acknowledged Resident #20's admission MDS, dated [DATE], was inaccurate regarding the resident's skin condition because the resident had one pressure injury presenting as deep tissue injury to the resident's left heel. The question of number of unstageable pressure injuries presenting as deep tissue injury should had been answered one. Further interview with the MDS nurse LVN-B stated she did not know what reason she answered inaccurately to the resident's annual MDS. The potential harm was Resident #20 might not receive correct wound care because of inaccurate MDS assessments. Interview on 10/10/2024 at 3:45PM MDS nurse LVN-B stated she acknowledged Resident #18's admission MDS dated [DATE] was inaccurate for the oxygen therapy not coded and that it did not affect the resident because Resident #18 received the oxygen per physician orders. LVN B stated the purpose of the MDS is for financial reimbursement. LVN B agreed the MDS and the Care Plan should reflect each other. Interview on 10/10/2024 at 3:54PM the Administrator stated the MDS should be correct and accurate because it explained the correct care that should be provided as well as financial reimbursements for the facility. The Administrator agreed the Care Plan and the MDS should have the same information. Interview on 10/10/2024 at 3:57PM the DON stated the MDS should be accurately coded to reflect the residents' needs and the care needed to provide, that it should match the residents' needs. The DON reviewed the MDS for Resident #15 for falls that was not coded and the MDS for Resident #5 for falls not coded. The DON also reviewed the MDS for Resident #18 for oxygen not coded. The DON agreed the MDS, and the CP should match one another. Interview on 10/11/2024 at 3:00 p.m. with DON stated the facility did not have specific policies regarding MDS assessments. The facility was following the CMS guidelines for MDS assessments. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . 675542 Page 4 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions. (Resident #78) The facility failed to develop Resident #78's baseline care plan dated 10/01/2024 regarding the resident's physician order dated 10/01/2024 for colostomy care within 48 hours of admission on [DATE]. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #78's face sheet, dated 10/10/2024, reflected the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnosis of laceration of sigmoid colon (injury that can occur after penetrating trauma to the abdomen), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), colostomy status (artificial opening in the abdominal wall to allows stool to be excreted through the skin), anemia (not have enough red blood cells), hypertension (high blood pressures), and dysphagia (swallowing difficulty). Record review Resident #78's baseline care plan, dated initiated 10/01/2024, reflected there was no baseline care plan regarding Resident #78's colostomy care. Record review of Resident #78's physician order, dated 10/01/2024, reflected the resident had the order of Change colostomy bag every day 72 hours and as needed, colostomy care, and colostomy appliance change weekly and as needed. Observed on 10/10/2024 at 11:37 a.m. revealed Resident #78 had colostomy as evidence by LVN-A emptied Resident #78's colostomy bag in the resident's room. Interview on 10/10/2024 at 11:37 a.m. LVN-A stated Resident #78 was admitted to the facility on [DATE] and had a colostomy when admitted . Interview on 10/10/2024 at 4:45 p.m. MDS nurse (LVN-B) acknowledged Resident #78 had colostomy when the resident was admitted to the facility on [DATE]. Further interview with the MDS nurse LVN-B stated she should have developed Resident #78's baseline care plan within 48 hours regarding the resident's colostomy care because the resident was admitted with colostomy. The MDS nurse LVN-B said she might think not developing baseline care plan related to colostomy was fine because Resident #78 had physician orders related to colostomy. Interview on 10/11/2024 at 1:58 p.m. DON stated the MDS nurse should have developed Resident #78's baseline care plan within 48 hours regarding the resident's colostomy care because the resident was admitted with colostomy, and baseline care plans affected [NAME] through which CNAs knew how to provide care appropriately to Resident #78; therefore, no baseline care plan might affect inappropriate care to the resident. 675542 Page 5 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0655 Record review of the facility policy, titled Care Planning, undated, reflected To write activity goals and approaches based on MDS triggers and current needs of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675542 Page 6 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

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, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #1) whose records were reviewed for care plan revision/timing, in that: Resident #1's care plan dated 08/25/2022 was not updated after her quarterly MDS assessment, dated 09/05/2024, reflected she was always incontinence to bowel. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings included: Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring seizures), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS score was 9 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #1's quarterly MDS, dated [DATE], indicated the resident was always incontinence to bowel and for toilet transfer, the resident was not attempted due to medical condition or safety concerns. Record review of Resident #1's care plan, date revised 08/25/2022, revealed Resident #1 required one staff participation to use toilet. Observation on 10/10/2024 at 2:04 p.m. revealed CNAs provided incontinence care, including changing a brief, for bladder and bowel to Resident #1. Interview on 10/11/2024 at 8:35 a.m. with LVN-A stated Resident #1 could not use toilet anymore. The resident was always incontinence to bladder and bowel. Interview on 10/11/2024 at 8:38 a.m. with the MDS nurse LVN-B acknowledged the MDS nurse did not update Resident #1's care plan regarding the resident's incontinence care to bowel because the resident could not use toilet anymore for her bowel movement. Further interview with the MDS nurse said when she revised Resident #1's care plan on 08/25/2022, the resident could use toilet with one staff's assist when she had bowl movement, but when she assessed Resident #1 on 09/05/2024 for quarterly MDS, the resident could not use toilet anymore. The resident was incontinence to bowel all the time. The MDS nurse should have updated Resident #1's care plan after quarterly MDS dated [DATE]. Interview on 10/11/2024 at 9:00 a.m. with the DON said the MDS nurse should have updated Resident #1's care plan after quarterly MDS dated [DATE] because the resident was incontinence to bowel all the time and could not use toilet anymore. The potential harm was staff might provide incorrect care 675542 Page 7 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0657 to Resident #1. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, titled Care Planning Assessment, undated, revealed . 2. When a comprehensive MDS assessment is done, the CAA's will be completed for each triggered area. From the CAA, it is determined which area need to be care planned to provide the necessary care for the resident. Residents Affected - Few 675542 Page 8 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and safe environment to prevent accidents for 1 of 12 residents (Residents #20) reviewed for environment. The facility failed on 10/08/2024 when there was one used disposable razor found on the sink faucet of Resident # 20's bathroom. This deficient practice cause infection or other physical injuries to residents and even staff. Findings included: Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and re-admitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing of the spinal canal). Record review of Resident #20's admission MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflecting he had moderate cognitive impairment. Further record review of Resident #20's admission MDS, dated [DATE], indicated the resident required dependent to staff for shower/bathe self and chair-to-bed transfer and required substantial/maximal assistance (helper does more than half the efforts) to personal hygiene. Record review of Resident #20's care plan, dated revised 09/17/2024, revealed [Resident #20] has an activities of daily livings self-care performance deficit related to left sided hand contractor and weakness. For interventions, assist personal hygiene. Observation on 10/08/2024 at 9:50 a.m. revealed one old disposable razor was on the sink faucets in Resident #20's bathroom. Interview on 10/08/2024 at 10:21 a.m. with LVN-A acknowledged she saw one old disposable razor was on the sink faucet in Resident #20's bathroom. Further interview with the LVN-A stated Resident #20 could not use the razor by himself. The resident's family might bring and use it for him. However, staff had responsibility to discard any used disposable razor to a sharp container after using it to prevent infection and for safety. The potential harm was other confused residents might use it and could cause physical injury or infection. Interview on 10/11/2024 at 1:58 p.m. with the DON stated staff should have discarded the old disposable razor to a sharp container after every use to prevent infection and physical injury. Record review of the facility policy, titled Infectious waste, handling of, undated, revealed 4. Disposable items, contaminated with resident excretions or secretions must be placed in red plastic bags, sealed, and placed in biohazard storage until removal from the premises. 675542 Page 9 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

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. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (A and B hall nursing cart) reviewed for pharmacy services. There was one medication (Benadryl itching stopping gel topical for skin use only) expired on 05/2021 found inside A and B hall nursing cart on 10/9/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 10/09/2024 at 1:54 p.m. revealed one gel of Benadryl itching stopping gel topical for skin use only was found inside A and B hall nursing cart, and it was expired 05/2021. Interview on 10/09/2024 at 2:00 p.m. with ADON acknowledged one gel of Benadryl itching stopping gel topical for skin use only was found inside A and B hall nursing cart, and it was expired 05/2021. Further interview with the ADON said she did not know what reason the expired medication was inside the nursing cart, and nurses should discard all expired medications from the medication carts as the facility policy. Potential harm was nurses might use the expired medication, and the expired medication might not have therapeutic effects. Record review of the facility policy, titled Medication Storage, undated, reflected 7. Expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with community policy. 675542 Page 10 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to 1 of 12 residents (Resident #9) reviewed for medications at the bedside. Resident #9's ear wax remove kit was left unattended and unsecured on the nightstand at the resident's bedside on 10/08/2024. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Record review of Resident #9's face sheet, dated 10/10/2024, reflected the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses included: pneumonia (lung infection), hypomagnesemia (low magnesium in the blood), cerebral vascular disease (problems with blood flow to the brain), heart failure (heart unable to pump enough blood), dementia (decline in mental abilities), and hypertension (high blood pressures). Record review of Resident #9's admission MDS, dated [DATE], reflected her BIMS score was 3 of 15 reflecting she had severe cognitive impairment. Further record review of Resident #9's admission MDS, dated [DATE], indicated the resident required supervision or touching assistance (helper provides verbal clues or touching assistance as resident completes activity) to eating and substantial/maximal assistance (helper does more than half the effort) to chair/bed-to-chair transfer. Observation on 10/08/2024 at 10:44 a.m. revealed in Resident #9's room, one box of the ear wax remove kit was on the nightstand at the resident's bedside unattended. Resident #9 was not in her room. Interview on 10/08/2024 at 10:49 a.m. with LVN-D stated Resident #9's ear wax remove kit was on the nightstand at the resident's bedside unattended. Further interview with the LVN-D stated it might be medication, and all medications should not be in resident's room. They did not know the reason the medication was on the nightstand unattended in Resident #9's room. The resident's family might bring it. The potential harm was that Resident #9 or other residents might use the medication incorrectly. Interview on 10/11/2024 at 1:58 p.m. the DON stated all medications should not be in resident's room unattended per the facility policy. Record review of the facility policy, titled Medication Storage, undated, revealed 1. Medications, prescriptions, over the counter and CAM (complementary and alternative medicine) will be stored in a locked cabinet, cart or medication room accessible to authorized personnel. 675542 Page 11 of 17 675542 10/11/2024 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 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, in that: Residents Affected - Some During observation of the kitchen on 10/08/2024 at 10:01AM with the DM revealed: 1. There was a bag of kernel corn left open in the walk-in freezer. 2. There was container with slices of turkey not labeled or dated in the walk-in cooler. 3. There was a bag with two rolls left open in the dry storage room. 4. There was a box of oatmeal with the top off in the dry storage room. 5. There were six containers of seasoning not closed in the dry storage room. 6. There were two backpacks stored on a shelf next to food in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 10/08/2024 at 10:01AM revealed there was a bag of kernel corn in a box left open on a shelf in the walk-in freezer. The DM stated they should not be left open in the freezer and should have been placed in a zip lock bag. Observation and interview on 10/08/2024 at 10:02AM revealed a container with turkey not labeled or dated in the walk-in cooler. The DM stated he did not know the sliced turkey was in the cooler in the container and he did not know how long it had been there. Observation on 10/08/2024 at 10:03AM revealed a bag with two rolls open in the dry storage room. Observation on 10/08/2024 at 10:03AM revealed a box of oatmeal with the lid off in the dry storage room. Observation and interview on 10/08/2024 at 10:04AM revealed two backpacks that belonged to employees on the shelf next to foods. The DM stated the staff did not have anywhere to place their belongings but in the dry storage room was not the place to put them. Observation on 10/08/2024 at 10:04AM revealed six bottles of seasoning left open. During an interview on 10/09/2024 at 10:10AM the DM stated the foods that were found open in the freezer and the seasoning containers that were open would cause bacteria to enter the food and could cause food borne infection. He stated the food in the freezer that was opened could decrease the quality of the food with freezer burn as well as food borne illness. He stated the 2 backpacks that 675542 Page 12 of 17 675542 10/11/2024 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 - Some belonged to the staff that was in the dry storage area on the shelf next to food was not the appropriate place to be stored. He stated, once again, that would not be good infection control. During an interview on 10/09/2024 at 12:13PM DA stated it was important to serve the residents in a clean environment because the residents could easily get an illness if the food was not served in a clean manner. She stated personal items should not be stored near the food whether cooked or not because it could pass bacteria to the food. Record review of facility policy titled Storage- Dry Goods undated revealed 2. Food storage areas are to be used for food and paper products only; 6. Opened packages are resealed to prevent contamination. Review of facility policy 3-17 Food Storage, 2013, revealed, 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. 675542 Page 13 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #20) of 12 residents reviewed for accuracy and completeness of clinical records. Wound care nurse RN-C documented on the skin evaluation, dated 08/21/2024 Resident #20's deep tissue injury was to the resident's right heel, when the resident had deep tissue injury to his left heel on 10/10/2024. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record. Findings included: Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and re-admitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing of the spinal canal). Record review of Resident #20's care plan, dated initiated 08/21/2024, revealed Resident #20 had pressure injury to sacrum and left heel. For intervention, administering treatments as ordered and monitor for effectiveness. Record review of Resident #20's physician order, dated 09/30/2024, revealed the resident had the order of Wound care to left heel - cleanse with normal saline, pat dry, apply skin prep to peri-wound, then apply nickel thick Santyl ointment to wound bed, then calcium alginate, and cover with dry dressing every day and as needed. Record review of Resident #20's admission MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflecting he had moderate cognitive impairment. Further record review of Resident #20's admission MDS, dated [DATE], indicated the resident required dependent to staff for put on/take off footwear and chair/bed-to-chair transfer. Record review of Resident #20's skin evaluation, dated 08/21/2024, revealed the resident had pressure injury to sacrum and deep tissue injury to right heel. Observation on 10/10/2024 at 12:12 p.m. revealed wound care nurse RN-C provided wound care as ordered to Resident #20. There were two pressure injuries. One was sacrum area (buttock area), and the other was left heel. Interview on 10/10/2024 at 12:12 p.m. with wound care nurse RN-C acknowledged Resident #20 had pressure injury presenting as deep tissue injury to the resident's left heel. There was no skin problem to the resident's right heel. The wound care nurse assessed Resident #20's skin on 08/21/2024 and documented the resident had deep tissue injury to his right heel on the skin evaluation form. It was 675542 Page 14 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incorrect because Resident #20 had deep tissue injury to his left heel. Further interview with the wound care nurse said she was mistaken when she documented, and the potential harm was Resident #20 might have resulted in lack of wound care or incorrect wound care due to misinformation by inaccurate medical record. Interview on 10/11/2024 at 3:00 p.m. with the DON said the facility did not have policy regarding medical record, but medical records should be accurate to reflect correct medical status for residents. 675542 Page 15 of 17 675542 10/11/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #1) of 12 residents reviewed for infection control. Residents Affected - Few The facility failed on 10/08/2024 to discard in a red plastic bag, sealed, and placed in biohazard storage a Suction tube Yankauer (oral suction tool used in medical procedure) that was found opened, covered in the plastic bag, connected to the suction machine and was on Resident #1's nightstand. The Yankauer appeared to be dirty with brown colored residual. These deficient practices affect residents who require suction and could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring seizures), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS score was 9 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #1's quarterly MDS, dated [DATE], indicated the resident required partial/moderate assistance 9helper does less than half for the effort) to oral hygiene. Record review of Resident #1's care plan, date initiated 02/19/2020, revealed [Resident #1] has a potential for aspiration. For intervention - suction as needed and ordered. Observation on 10/08/2024 at 10:01 a.m. revealed a suction tube Yankauer opened covered in the plastic bag connected to the suction machine was on Resident #1's nightstand, and the Yankauer was dirty with brown colored residual. Interview on 10/08/2024 at 10:25 a.m. with LVN-A stated Yankauer opened covered in the plastic bag connected to the suction machine was on Resident #1's nightstand, and the Yankauer was dirty with brown colored residual. Further interview with the LVN-A said nurses should discard the Yankauer after every using it to prevent infection. The nurse did not know what reason the Yankauer was on Resident #1's nightstand. The potential harm was the resident could have infection. Interview on 10/11/2024 at 1:58 p.m. with the DON stated nurses should discard the Yankauer after every using it to prevent infection. Record review of the facility policy, titled Infectious waste, handling of, undated, revealed 4. Disposable items, contaminated with resident excretions or secretions must be placed in red plastic 675542 Page 16 of 17 675542 10/11/2024 Juniper Village at Lincoln Heights 855 E Basse Rd San Antonio, TX 78209

F 0880 bags, sealed, and placed in biohazard storage until removal from the premises. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675542 Page 17 of 17