Health inspection·August 31, 2023

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler pivot assist bars with the resident or resident representative and obtain informed consent prior to installation for three (Residents #81, #312, #314) of 37 resident rooms observed and reviewed for bed rails/pivot assist bars in that: The facility failed to have consents signed for the pivot assist quarter bed rails for Residents #81, #312, and #314. This failure could affect residents who used bed rails/pivot assist bars at risk of the resident/responsible party not being aware of the risk. Findings included: 1. Record review of Resident #81's face sheet, dated 08/31/2023 revealed resident was originally admitted on [DATE] and current admit on 03/23/2023 with diagnoses of Pneumonia, unspecified organism; Paroxysmal atrial fibrillation; Unspecified dementia, unspecified severity, without behavioral/psych/mood; Hypothyroidism, unspecified; Muscle weakness (generalized); Difficulty in walking, not elsewhere classified; Cognitive communication deficit; Other abnormalities of gait and mobility; Essential (primary) hypertension; Other lack of coordination; Unsteadiness on feet; Need for assistance with personal care; Unspecified lack of coordination. Per the face sheet, Resident #81's responsible party was a family member. Review of Resident #81's MDS, dated [DATE], revealed the resident had issues with forgetfulness. Resident needed assistance with all ADL care. Resident was not able to move from seated to standing position, move on and off toilet, or perform a surface-to-surface transfer without the assistance of staff. Resident used a wheelchair for mobility. Review of Medical record of Resident #81 revealed no written Physician Order for quarter bed rails (pivot assist bars) for mobility and positioning. Review of Medical Record of Resident #81 revealed no Physical Device Acknowledgement form (bed rail/pivot assist consent) for the pivot assist bars (quarter bed rails) signed by the resident's responsible party. Record review of Resident #81's Care Plan, dated 3/23/2023, revealed no indication of bed rail or Page 1 of 7 675592 675592 08/31/2023 C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214

F 0700 pivot assist bar discussion of risks and benefits with Resident or responsible party. Level of Harm - Minimal harm or potential for actual harm Observation on 08/29/2023 at 9:50 AM revealed Resident #81's room revealed the resident's bed with quarter bed rails/pivot assist bars raised on both sides of bed with call light laying on the mattress. Residents Affected - Some Observation on 08/30/2023 at 02:05 PM of Resident #81's room revealed both quarter bed rails/pivot assist bars raised on resident's bed. Observation on 08/31/2023 at 08:42 AM of Resident #81's room revealed both quarter bed rails/pivot assist bars raised on resident's bed. 2. Record review of Resident #312's face sheet dated 08/31/2023 revealed resident's current admit date of 08/24/2023, initial admit date of 08/19/2023, with diagnosis of Stable burst fracture t11-t12 vertebra, subs for fracture with ro; Parkinson's disease; Unspecified fall, subsequent encounter; Hyperlipidemia, unspecified. Per face sheet, the responsible party was the resident, spouse listed as emergency contact. Record review of Resident #312's Care Plan, dated 08/31/2023, revealed resident is a fall risk and has a history of falls. Record review of Resident #312's Physician Orders reveals twice daily medication for dementia. Review of Medical record of Resident #312 revealed no written Physician Order for quarter bed rails (pivot assist bars) for mobility and positioning. Review of Medical record of Resident #312 reveals no Physical Device Acknowledgement form (bed rail/pivot assist bar consent) for the pivot assist bars (quarter bed rails) signed by the resident's responsible party. Record review of Resident #312's Care Plan, dated 08/31/2023, revealed no indication of bed rail or pivot assist bar discussion of risks and benefits with Resident or responsible party. Observation on 08/29/2023 at 09:35 AM revealed Resident #312 sitting in wheelchair in room. Resident #312's bed was equipped with quarter bed rails (pivot assist bars) that were raised. Observation on 08/30/2023 at 2:54 PM revealed Resident #312's bed observed with both quarter bed rails/pivot assist bars raised. Observation on 8/31/2023 at 10:15 AM of Resident #312's empty room revealed both quarter bed rails/pivot assist bars raised. 3. Record review of Resident #314's face sheet dated 08/31/20232 revealed resident was admitted on [DATE], with a current admit date of 2/22/2023, with diagnosis of Encephalopathy, unspecified; Sepsis, unspecified organism; Urinary tract infection, site not specified; Cerebral infarction, unspecified; Type 2 diabetes mellitus without complications; Generalized anxiety disorder; Depression, unspecified; Essential (primary) hypertension; Hyperlipidemia, unspecified; Unsteadiness on feet; Other lack of coordination; Need for assistance with personal care; Difficulty in walking, not elsewhere classified; Muscle weakness(generalized). Per the face sheet, the responsible party was the resident. 675592 Page 2 of 7 675592 08/31/2023 C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Medical record of Resident #314 revealed no written Physician Order for half bed rails (pivot assist bars) for mobility and positioning. Review of Medical Record of Resident #314's Care Plan, undated with updates made between 6/22/2023 and 7/27/2023, revealed there was no care plan addressing the use of bilateral half bedrails or pivot assist device on resident's bed. Review of Medical record of Resident #314 reveals no Physical Device Acknowledgement form (bed rail/pivot assist bars consent) for the pivot assist bars (half bed rails) signed by the resident's responsible party. Observation on 08/29/2023 at 10:03 AM revealed Resident #314 sitting in bed watching television with both half bedrails/pivot assist bars raised. Call light was wrapped on the bed rail. Observation on 08/30/2023 at 02:55 AM revealed Resident #314 lying her in bed sleeping with television on. Resident #314's bed was equipped with half bed rails (pivot assist bars) that were raised on each side. Observation on 8/31/2023 at 09:55 AM revealed Resident #314 in bed eating breakfast; both half side rails/pivot assist bars were raised. In an interview with Administrator on 8/31/2023 at 10:35 AM, the facility has used the pivot assist enabler bars on every bed in the facility since 2020 and had not obtained physician orders or signed consent. Administrator A maintains that the pivot assist bars are not bed rails and bases this on the manufacturer's product statement flyer and that the beds are custom. Administrator A stated the pivot assist bars can swing out to aid in standing if an individual is sitting on the edge of the bed. Administrator A, in an email dated 8/31/2023 at 11:17 AM, when asked for consents for bed rail/pivot assist bars stated however we will not have consent forms for the assistive devices as they are not side rails and therefore not required. In an interview on 08/31/2023 at 8:58 AM, DON reviewed facility process and policy for bed rail and grab bars/pivot assist bars use. DON stated the bed rails and grab bars/pivot assist devices are used for residents for positioning and comfort. DON stated that on admission residents are informed about the facility use and evaluated for extent of need for bed rails and grab bars/ pivot assist bars; Residents were also reviewed quarterly or when care is plan updated. DON stated this facility did not call them bed rails rather they called them supportive devices. DON stated that the grab bars/pivot assist bars were also used to anchor the call light cable to make sure it did not fall on ground and was more available for resident use. DON stated that when a family member or resident did not want the grab bars/pivot assist bars to be used, the facility would put them in a down position or have them removed. DON stated that electronic health records should be updated with resident evaluations for safe use of bed rails and grab bars/pivot assist bars and that staff should be reviewing and familiar with resident status in their care areas. Interview with LVN A on 8/30/23 at 1:36 PM about bed rail or grab bar/pivot assist bar use in the facility. LVN A stated she would check orders for new residents for information on need for bed rails or grab bars/pivot assist bars being used or if a change in use or position of the bars is noticed. LVN A stated that bed rails can be a hazard as a resident could be hurt by choking on a cord anchored on the rail, having limb caught in the open spaces of the bar resulting in fractures or injury. 675592 Page 3 of 7 675592 08/31/2023 C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214

F 0700 Level of Harm - Minimal harm or potential for actual harm Interview with LVN B on 8/30/23 at 2:10 PM about bed rail or grab bar/pivot assist bar use in the facility. LVN B stated she checks the electronic chart of residents she was not familiar with for the reasoning for use of bed rails or grab bars/pivot assist bars. LVN B stated that bed rails or grab bars/pivot assist bars can be dangerous due to the potential of injury to a resident getting caught in the bars and because the bars may be seen as a restraint. Residents Affected - Some Interview with CNA C on 8/30/23 at 1:55 PM about bed rail or grab bar/pivot assist bar use in the facility. CNA C states that she would verify with a floor nurse if she saw a change in use of bed rails or grab bars/pivot assist bars for a resident and verified what the need for the bars or change in use. CNA C stated that bed rails and grab bars/pivot assist bars can be a danger as they can be a restraint and limit mobility of a resident. Facility provided product statement flyer, undated, by [Company Name], the manufacturer of the bed rails/grab pivot assist bars in use by facility. The statement states that the product is not a bed rail but a three position pivoting assist device . and does not fulfill all the criteria indicated in CMS F604 §483.10 Euro Respect and Dignity. Facility Administrator states that as the manufacturer Product Statement is specific that these pivot assist bars are not side rails that the facility does not care plan their use, obtain consent or physician orders. Record review of the facility's provided Proper Use of Side Rails, ©2001 [Company Name] (Revised December 2016), revealed the purpose To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guideline item #2 states Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. General Guideline #3 states An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. General Guideline #4 states The use of side rails as an assistive device will be addressed in the resident care plan. 675592 Page 4 of 7 675592 08/31/2023 C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214

F 0700 Level of Harm - Minimal harm or potential for actual harm General Guideline #5 states Consent for using restrictive devices will be obtained from resident or legal representative per facility protocol. General Guideline #7 states Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. Residents Affected - Some No General Guideline item indicated need for a physician order before side rails or pivot assist bars can be used or installed. 675592 Page 5 of 7 675592 08/31/2023 C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214

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 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 infections for one (CMA D) of two staff observed during medication pass reviewed for infection control. Residents Affected - Few 1. CMA D failed to disinfect the blood pressure cuff in between use with Resident #1 and Resident #91. These failures could affect all residents by causing cross contamination and placing them at risk for exposure to a contagious disease, infection, and possible hospitalization. Findings included: 1. Record review of Resident #1 face sheet dated 8/31/23.admitted to the facility at 8/19/23 with diagnosis of urinary tract infection, and hypertension (high blood pressure). Observation on 8/30/23 at 8:15AM with CMA D revealed him going into Resident #1 room to take his blood pressure. He placed the blood pressure machine on the bed while receiving a reading. Once CMA D was done, he came out of the room. Placed the blood pressure machine back on his cart without sanitizing the cuff. He then Sanitized his hands to prepare Residents #1 medication. Once he finished given the medication, he washed his hands to prepare to go to the next resident room. Record review of Resident #91 dated 8/31/23 admitted [DATE] with diagnosis of hypertension (high blood pressure), depressive episodes, and muscle weakness. Observation on 8/30/23 at 8:27AM with CMA D went to Resident #91 room and took the non-sanitized blood pressure cuff in the room to take his blood pressure. After that CMA D sanitized his hands to prepare Residents #91's medications and placed the non-sanitized blood pressure cuff on the medication cart. Interview on 8/30/23 at 8:35AM revealed CMA D had been trained to sanitize multi-use devices such as the blood pressure cuff right after using it on a resident and in between residents. He stated they have wipes that were supposed to be used but he forgot to use them. Interview on 8/30/23 at 2:23PM with the Administrator revealed when dealing with multi use devices she expected her staff to disinfect and clean in between residents. The Administrator revealed the risk of not doing so could lead to the spread of infection. She also stated they do infection control once a month and every couple of weeks go around to watch medication passes to make sure staff are following the appropriate protocol. Record Review dated September 2022 of Cleaning and disinfection of resident-care items and equipment policy revealed, Reusable items are cleaned and disinfected or sterilized between residents (eg. Stethoscopes, durable medical equipment 675592 Page 6 of 7 675592 08/31/2023 C C Young Memorial Home 4849 W. Lawther Dr. Dallas, TX 75214

F 0880 Reusable resident care equipment is decontaminated and or sterilized between resident according to manufacturer's instructions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675592 Page 7 of 7