Health inspection·October 17, 2023

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. Based on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1one of 1 (3000 Medication Carts) medication carts reviewed for medication storage. The facility failed to ensure the 3000-medication cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings include: In an observation and interview on 10/17/23 at 11:21 AM Medication Aide A passed medication to residents and left the 3000-medication cart unlocked and unattended while entering the resident room and closing the door behind her. There was no staff or residents observed on the hall near the 3000-medication cart. Interview with Medication Aide A stated she had worked in the facility PRN for one year. Medication Aide A stated she would typically lock the medication cart each time she left it unattended however she was nervous and forgot. Medication Aide A stated the risk of leaving the Medication Cart unlocked would be someone would have access to the medication. The medication cart was observed to have routine medication, eye drops and nasal sprays. Interview on 10/17/23 at 2:06 PM with the Director of Nursing revealed the medication aides were aware of the expectation to lock the medication carts when they were not within eyesight. The Director of Nursing stated she had in serviced the medication aides on the floor after she was informed about the medication cart being unlocked. The Director of Nursing stated the risk of leaving the medication cart unlocked would be staff or residents would have access to the medication. Record review of the facility's policy titled, Medication access and storage/ drug destruction, policy dated July/2023 revealed, It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Page 1 of 4 675611 675611 10/17/2023 The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 2 residents (Resident #1) reviewed for preference. The facility failed to honor Resident #1's food dislikes. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of the electronic face sheet undated revealed an 81 year- old- female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of acute and chronic respiratory failure (shortness of breath), Oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition. Section GG regarding eating indicated setup or cleanup assistance needed. Record review of the care plan dated revised 10/11/23 indicated Resident#1 had potential for nutritional problems. Interventions included diet as ordered by physician, regular consistency, and thin liquids, if eat less then 50% offer meal replacement. Review of the Resident #1 food and beverage preference undated revealed special food request for each meal, no rice. Interview and Observation on 10/17/23 at 12:50PM with Resident#1 revealed she continued to receive rice during meals although she had informed the kitchen staff that she did not want rice on the plate several times. Resident # 1 stated when she was served rice, she would not eat her meal and did not receive a meal replacement. Resident#1 stated each time rice is on the menu she is continually served rice. Observation of the resident revealed rice on her plate for lunch. Interview on 10/17/23 at 3:00PM with the Dietary Manager revealed she completed a food and beverage preference sheet with residents upon admission. She stated she had recently updated all resident preference sheets. The Dietary Manager reviewed the preference sheet and confirmed that Resident #1 had a preference of no rice. The Dietary Manager stated the cook overlooked the preference sheet however she would in -service all kitchen staff today (10/17/23) regarding ensuring resident food preferences are followed. Interview on 10/17/23 at 4:15 PM with the Administrator revealed he was informed by the Dietary Manager regarding food preferences not being followed. The Administrator stated with staff turn overs there was an opportunity to in- services new staff which the Dietary Manager had completed. The Administrator stated there was no policy regarding dietary preferences. 675611 Page 2 of 4 675611 10/17/2023 The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216

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 3 of 4 residents (Resident #2, Resident #3 and Resident#4 ) reviewed for infection control practices, in that: Residents Affected - Few The facility failed to ensure Medication Aide A performed hand hygiene between medication administration for Residents #3,#4 and #2, and sanitized the blood pressure cuff between use on Resident #3 and #2. These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health. The findings included: 1. Record review of Resident #2's undated electronic face sheet revealed a 73- year-old female admitted to the facility on [DATE] and re admitted [DATE] with diagnosis of dementia without behavioral disturbances and type 2 diabetes mellitus without complications and hypertension (high blood pressure). Record review of Resident #2's most recent annual MDS assessment, dated 8/27/23 reflected a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #2's care plan revision date 10/11/23 revealed the resident had diabetes mellitus with interventions of diabetes medication as order by a doctor. 2. Record review of Resident #3's's undated electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included sequela of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury has ended), hypertension (high blood pressure). Record review of Resident #'3's admission MDS assessment, dated 9/5/23 revealed a BIMS score of 14 which indicated the resident was cognitively intact. Record review of Resident #3's care plan dated revised 9/6/23 revealed hypertension with interventions to include avoid taking blood pressure readings after physical activity, blood taken with blood pressure cuff. 3. Record review of Resident #4's undated electronic face sheet revealed a [AGE] year old female admitted to the facility 12/20/22 and re admitted [DATE] with diagnosis of cellulitis of the right lower limb (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), and hypertension( high blood pressure) Record review of Resident #4's quarterly MDS assessment dated [DATE] did not revealed a BIMS score. Record review Resident# 4's care plan dated revised 10/17/23 revealed hypertension with interventions of avoid taking blood pressure reading after physical activity, give hypertensive medication as 675611 Page 3 of 4 675611 10/17/2023 The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216

F 0880 directed. Level of Harm - Minimal harm or potential for actual harm Observation on 10/17/23 at 11:20AM during the medication pass revealed Medication Aide A took the digital wrist blood pressure cuff from the medication cart and went into Resident#3's room and obtained Resident#3's blood pressure with the digital wrist cuff. Medication Aide A proceeded to prepare Resident#3's medication and provided nasal spray without performing any hand hygiene before or after the medication pass. Medication Aide A then went to Resident#4's room to provide nasal spray and eye drops. Medication Aide A did not perform hand hygiene before or after putting on gloves to provide the nasal spray and eye drops to Resident #4. Medication Aide A then went to Resident #2's room and used the same blood pressure cuff off the cart without sanitizing it to obtain Resident#2's blood pressure. Medication Aide A provided Resident#2 with medication without sanitizing her hands before or after the medication pass. Residents Affected - Few Interview on 10/17/23 at 11:45 AM with Medication aide A revealed she had worked in the facility for 1 year as PRN. Medication Aide A stated she did not have any hand sanitizer on the cart and was not sure where to obtain the hand sanitizer. Medication Aide A stated she should have completed hand hygiene in between each resident. Medication Aide A stated the risk of not completing hand hygiene would be that infection could have been spread. Interview on 10/17/23 at 2:06 PM with the Director of Nursing revealed the medication aides were aware of the expectation to practice hand hygiene between each medication pass. The Director of Nursing revealed that she had in- serviced the Medication Aides today 10/17/23 regarding hand hygiene. The Director of Nursing stated the risk of not practicing hand hygiene would be that infection could be spread. Interview on 10/17/23 at 4:15 PM with Administrator revealed the Medication Aide A was nervous due to the surveyor observing her which was why she did not practice hand hygiene. The Administrator stated the Medication Aide was in- serviced regarding hand hygiene. Review of the facility policy Infection prevention and control program infection control revised October 2020, Goals- decreased the risk of the infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control. Promote individual resident's rights and wellbeing while trying to prevent and control the spread of infection. Monitor personnel health and safety. 675611 Page 4 of 4