Health inspection·November 30, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assist with residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #1 and Resident #2) reviewed for ADL's. Residents Affected - Few -Resident #1 fingernails were observed with black debris underneath the nails. -Resident #2 was observed with a moderate amount of facial hair growing on her chin. These failures could place residents at risk for low self-esteem and decrease in dignity. Findings: Resident #1 Record review of Resident #1's face sheet revealed an 60year old female admitted to the facility on originally 03/01/2021 and again on 09/29/2023 with the diagnoses that included the following; malignant otitis externa (severe infection that affects the outer ear canal, skull base, and temporal {temple region of the head}) of left ear, end stage renal disease (pertaining to the kidney), type two diabetes mellitus, hypertension (elevated blood pressure), dependence of renal dialysis, blindness right eye, absence of left leg below the knee, major depression, fatigue, hyperlipidemia (elevated cholesterol), and peripheral vascular disease (fatty deposits build up in the arteries causing them to narrow and stiffen). Record review of Resident #1's MDS dated [DATE] revealed the residents BIMS score was 10 indicating resident cognition was moderately impaired. Further review section GG (functional abilities) revealed that resident required partial to moderate assistance with personal hygiene. Record review of Resident #1's Care Plan dated 09/29/2023 revealed that resident was being care planned for ADL self-care performance with an intervention for personal hygiene: The resident required supervision or touching assistance by staff with personal hygiene. Further review revealed that resident was also being care planned for impaired visual function r/t blindness of right eye with intervention to monitor/document/report PRN any s/sx of acute eye problems: change in ability to perform ADL's. Observation on 11/30/2023 at 1:21PM Resident #1 sitting in wheelchair dressed in street clothing. Resident left lower extremity was amputated (removed surgically) below the knee. Further observation was made of both resident hands with black debris under the nails on both hands. Page 1 of 5 675700 675700 11/30/2023 Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

F 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 11/30/2023 at 1:25PM Resident #1 said she could not remember the last time the staff had cleaned underneath her fingernails and that she would like for her fingernails to be cleaned. Further observation of CNA B taking Resident #1 to her room to clean resident fingernails. CNA B began to clean resident fingernails using the end of a q-tip swab removing thick black debris from underneath resident fingernails. Residents Affected - Few Interview on 11/30/2023 at 1:30PM The CNA B said she was not aware of Resident #1's fingernails being dirty. CNA B said normally the CNAs groom the resident fingernails. CNA B said Resident #1 had diabetes. CNA B said it was important to keep the resident nails groomed because it would make them feel better about themselves. Interview on 11/30/2023 at 1:32PM RN A said she never noticed Resident #1's fingernails being dirty. RN A said it was the facility wound care nurse that groomed resident fingernails that had diabetes. RN A said LVN C was the facility wound care nurse. RN A said when the resident nails were not groomed, it could place residents at risk for infections. Observation on 11/30/2023 at 1:44PM RN A placed Resident #1's hands in a basin of soapy water to soak. RN A began to remove the black debris underneath resident fingernails. When RN A finished removing the black debris from underneath resident fingernails, RN A began to clip resident fingernails. Resident #1 said she was not in any discomfort. Resident #1 smiled and said that her fingernails looked and felt better. Interview on 11/30/2023 at 3:00PM LVN C said the CNAs on the unit were supposed to groom the resident nails unless the resident had diabetes. LVN C said if the resident had diabetes, the unit nurse was supposed to groom the resident fingernails. LVN C said she was working another role at the facility but had been appointed this week the facility new wound care nurse. Interview on 11/30/2023 at 3:43PM the DON said she started working at the facility 11/27/2023. The DON said it was the CNAs that done the grooming for the residents on the resident shower days. The DON said if the resident had diabetes, the nurses on the units were responsible in grooming the resident fingernails. Resident #2 Record review of Resident #2's face sheet revealed an 81year old female admitted to the facility on [DATE] with diagnoses that included the following: Alzheimer's disease, heart disease, type 2 diabetes, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record review of Resident #2's MDS dated [DATE] revealed resident had a BIMS score of 6 indicating that resident cognition was severely impaired. Further review revealed that resident required extensive assistance with personal hygiene. Record review of Resident #2's Care Plan dated 06/21/2021 revealed that resident was being care planned for ADL self-care r/t End-Stage Alzheimer's with intervention that included intervention for personal hygiene requiring assistance by 1 staff with personal hygiene and oral care. Observation on 11/30/2023 at 2:00PM Resident #2 was sitting in wheelchair in front of the nurse station on Hall 500 dressed in street clothing. Further observation was made of resident having a large amount of long hair strands on her chin resembling a beard. Resident would pull at the hair on her 675700 Page 2 of 5 675700 11/30/2023 Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

F 0677 chin at intervals. Level of Harm - Minimal harm or potential for actual harm Interview on 11/30/2023 at 2:03PM with Resident #1 in her room said she did not like the hair on her chin. Resident said she wanted the hair from her chin removed but did not want to be shaved. Resident said she preferred for the hair to be plucked out instead. Resident said she tried to pull the hair out of chin herself sometimes. Residents Affected - Few Interview on 11/30/2023 at 2:06PM CNA D said she had been working at the facility for 2-3 months. CNA D said she was the CNA for Resident #2. CNA D said she was aware of the hair growing on resident chin but had not gotten around to removing the hair off resident chin. CNA D said it was important to keep the residents groomed because it would make the residents feel better about themselves. CNA D said she got off work at 2:00PM but would groom Resident #2's chin before she went home. Interview on 11/30/2023 at 2:14PM RN A said she was not aware of Resident #2 having facial hair on her chin. RN A said the CNAs were supposed to groom the residents on their shower days. RN A said to be honest, the shower aides paid closer attention to the details involving the resident's grooming. RN A said the facility no longer had a shower aide and that the CNAs done the showers. RN A said the CNAs did not paying attention to the details of grooming the residents because they do so many other tasks involving the care of the residents. Record review of the facility policy on Resident Rights-Dignity & Respect revised 10/2023 revealed in part: .All residents have rights guaranteed to them under Federal and State laws and regulations. Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices .Grooming residents as they wish to be groomed (e.g., hair combed and styled, beards shave/trimmed, nails clean and clipped) . 675700 Page 3 of 5 675700 11/30/2023 Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

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 infection for 1 of 5 residents (Resident #1) reviewed for infection. Residents Affected - Few -Resident #1s bedpan was laying on the floor in room over in a corner with no name on bedpan nor was the bedpan bagged. This failure placed resident at risk for unwanted infections. Findings: Record review of Resident #1's face sheet revealed an 60year old female admitted to the facility on originally 03/01/2021 and again on 09/29/2023 with the diagnoses that included the following; malignant otitis externa (severe infection that affects the outer ear canal, skull base, and temporal {temple region of the head}) of left ear, end stage renal disease (pertaining to the kidney), type two diabetes mellitus, hypertension (elevated blood pressure), dependence of renal dialysis, blindness right eye, absence of left leg below the knee, major depression, fatigue, hyperlipidemia (elevated cholesterol), and peripheral vascular disease (fatty deposits build up in the arteries causing them to narrow and stiffen). Record review of Resident #1's MDS dated [DATE] revealed that resident BIMS score was 10 indicating resident cognition was moderately impaired. Further review section GG (functional abilities) revealed that resident required partial/to moderate assistance toileting. Further review revealed that resident was occasionally incontinent of bowel and bladder. Record review of Resident #1's Care Plan dated 09/29/2023 revealed that resident was being care planned for ADL self-care performance with an intervention for personal hygiene and incontinence of bladder: Check the resident frequently and as required for incontinence. Observation on 11/30/2023 at 1:45PM in Resident#1's room over in a corner on the floor was a bedpan unlabeled and not stored inside of a plastic bag. Further observation was made of Resident #1 having a roommate who was confined resting in bed -A. Further observation revealed that resident roommate in A-bed was wearing a brief and not interview able. Interview with CNA B and RN A on 11/30/2023 at 1:50PM, CNA B said she was not aware of a bedpan being on the floor in Resident #1's room. CNA B said usually resident bedpans are labeled and stored inside of a plastic bag to prevent the spread of bacteria. CNA B said she never placed Resident #1 on the bedpan instead, took Resident #1 to the bathroom. RN A said Resident #1 also used the bedpan. Interview on 11/30/2023 at 3:43PM the DON said she started working at the facility 11/27/2023. The DON said bed pans should be labeled and placed in a plastic bag for infection control measures. Record review of the facility policy on Infection Prevention and control Program (undated) revealed the following: 675700 Page 4 of 5 675700 11/30/2023 Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

F 0880 .Purpose: Provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675700 Page 5 of 5