Health inspection·September 22, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for two of eleven (Resident #1 and Resident #2) residents reviewed for environment. The facility failed to ensure that Resident #1's room had repaired windowsill and wall. The facility failed to ensure that Resident#2's room had repaired walls. This failure could place residents at risk for living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Review of the face sheet for Resident #1 revealed a [AGE] year-old male admitted on [DATE] with an admitting diagnosis of insomnia, generalized muscle weakness, and high blood pressure. Review of the Quarterly MDS, dated [DATE], for Resident #1 revealed a BIMS score of 13 indicating resident was cognitively intact. MDS also revealed Resident #1 to need extensive assistance with bed mobility. Observation on 09/19/23 at 10:01 a.m., Resident #1's room revealed the left side of lower windowsill ledge detached and falling off to reveal the sheetrock. Below the windowsill there is a hole of what appears to be a rip in sheetrock extending to the floor. Interview with Resident #1 on 9/20/23 at 11:36 a.m. revealed that the windowsill has been in disrepair for about a year. Resident #1 states, It doesn't bother me though. Review of the face sheet for Resident #2 revealed a [AGE] year-old female initial admitted date on 04/16/2022, readmittance date on 04/16/2022 and 07/18/2023, and an admitting diagnosis of adult failure to thrive, generalized muscle weakness, and high blood pressure. Review of the Annual MDS, dated [DATE], for Resident #2 revealed a BIMS score of 15 indicating resident is cognitively intact. MDS also revealed Resident #2 to need supervision with bed mobility. Observation on 9/20/23 at 10:09 a.m., Resident #2's room revealed the wall next to the bed had a hole and sheet rock falling off wall. The measurements are approximately 2ft x 2ft. Page 1 of 5 675702 675702 09/22/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 9/20/23 at 10:11 a.m., Resident #2 states that the bed rubbing where the wall was falling apart makes a lot of noise. She states there was a hole, and the paint is gone. Resident #2 states, I do not like it. Pieces of the wall fall on me. Resident #2 was unsure of time frame, but states she thinks it has been like that for about two months. Interview on 09/20/23 at 10:33 a.m. with LVN A revealed that staff are to report maintenance issues by writing it in the logbook at the nurse's station. LVN A was unaware of the repairs needed for Resident #1 and Resident #2. LVN A states that the physical environment in good repair was to help with infection control, resident safety, and makes the resident feel good. Interview with Maintenance Director on 09/20/23 at 12:35 p.m. revealed that the staff are expected to put maintenance issues in the maintenance logbook at the nurse's station. Maintenance Director states that he looks at the book 2 to 3 times daily. Maintenance director states that the walls are like that due to staff pushing beds up against the wall and that he has repeatedly told staff not to push beds up against the walls. When questioned about how it affects residents, he stated they are used to it and understand it. Interview with the Administrator on 09/22/23 at 09:45 a.m., revealed that the current maintenance staff was new. Administrator states that they have ambassador rounds, which consists of department heads making rounds to look for and turn in any maintenance issues. Administrator stated that all staff are expected to write any maintenance issues in the maintenance book which was at the nurse's station. Administrator stated that the physical environment being in disrepair can cause health concerns or safety issues for residents. Record review of maintenance log revealed no recording of Resident #1's or Resident #2's room needing wall repair or windowsill repair in the months of September, August, or July 2023. Review of facility's policy Maintenance Services Operational Manual- Physical Environment dated 08/2020, reflected Purpose: to protect the health and safety of residents, visitors, and facility staff .the maintenance department maintains all areas of the building, grounds, and equipment .Director of Maintenance is responsible for conducting regular inspections that may include, but are not limited to: A. activity area B. Hallways .D. Resident . 675702 Page 2 of 5 675702 09/22/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

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 ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#3) of six residents reviewed for incontinent care. Residents Affected - Few The facility failed to ensure Resident #3 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #3's Comprehensive MDS assessment, dated 08/08/23, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #3's diagnoses included dementia and need for assistance with personal care. His BIMs score was not assessed. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Record review of Resident #3's comprehensive plan of care dated 08/23/23 reflected, Focus: Resident#3 has an ADL self-care performance deficit related to muscle weakness, blindness. Goals: resident## will demonstrate the appropriate use of adaptive device to increase ability in ( ., toilet use and personal hygiene) through the review date. Intervention: Toilet use: the resident requires limited 1 person assistance to use toilet. He is occasional incontinent of bowel and bladder. Observation and interview on 09/19/2023 beginning at 10:10 AM, CNA B was observed as she assisted Resident#3 to the toilet. The resident was wearing an incontinent brief which was swollen large with liquid. When asked if the resident had been checked and changed, CNA B stated she had not changed the resident since the start of her shift because she was late this morning. CNA B shift started at 6:00 AM. The surveyor observed the resident's skin, and no breakdown or redness was noted. Interview on 09/22/22 at 11:50 AM, the DON stated the charge nurses and CNAs supposed to do did walk and round room to room at least every 2 hours to check resident and change them if they are wet. The DON stated the risk of incontinent care not being provided on time would be skin break down, infection, and resident dignity. A record review of the facility's policy Resident Rights - Quality of Life, revised August 2020, reflected . Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, and individuality. XII. Demeaning practices and standards of care that compromise dignity are prohibited. Facility staff will promote dignity and assist residents as needed by . B. Promptly responding to the resident's request for toileting assistance . 675702 Page 3 of 5 675702 09/22/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment , received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #3) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #3 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #3's Comprehensive MDS assessment, dated 08/08/23, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #3's diagnoses included dementia and need for assistance with personal care. His BIMs score was not assessed. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Record review of Resident #3's comprehensive plan of care dated 08/23/23 reflected, Focus: Resident#3 has an ADL self-care performance deficit related to muscle weakness, blindness. Goals: resident#3 will demonstrate the appropriate use of adaptive device to increase ability in ( ., toilet use and personal hygiene) through the review date. Intervention: Toilet use: the resident requires limited 1 person assistance to use toilet. He is occasional incontinent of bowel and bladder. Observation and interview on 09/19/2023 beginning at 10:10 AM, CNA B was observed as she assisted Resident#3 to the toilet. The resident was wearing an incontinent brief which was swollen large with liquid. When asked if the resident had been checked and changed, CNA B stated she had not changed the resident since the start of her shift because she was late this morning. CNA B shift started at 6:00 AM. The surveyor observed the resident's skin, and no breakdown or redness was noted. Interview on 09/22/22 at 11:50 AM, the DON stated the charge nurses and CNAs supposed to do did walk and round room to room at least every 2 hours to check resident and change them if they are wet. The DON stated the risk of incontinent care not being provided on time would be skin break down, infection, and resident dignity. A record review of the facility's policy Resident Rights - Quality of Life, revised August 2020, reflected . Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, and individuality. XII. Demeaning practices and standards of care that compromise dignity are prohibited. Facility staff will promote dignity and assist residents as needed by . B. Promptly responding to the resident's request for toileting assistance . 675702 Page 4 of 5 675702 09/22/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

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 maintain an infection control program designed to prevent the development and transmission of infection for one (Resident #3) of six resident observed for infection control. Residents Affected - Few Facility failed to ensure CNA B performed hand hygiene and changed gloves while providing incontinence care to Resident # 3. This failure could place the residents at risk for infection. Findings included: Record review of Resident #3's Comprehensive MDS assessment, dated 08/08/23, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #3's diagnoses included dementia and need for assistance with personal care. His BIMs score was not assessed. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Observation on 09/19/23 at 10:25 AM revealed CNA B assisted Resident #3 to toilet use and incontinent care. CNA B was observed completing hand hygiene before care and donned clean gloves. CNA B assisted Resident#3 to set on the toilet. CNA B removed the incontinent brief which was swollen large with urine. CNA B gave peri-wipes to resident#3 to clean his front peri-area, after he agreed to do it. CNA B did not change gloves, she assisted Resident#3 to remove the dirty shirt and put on clean one. CNA B removed and discarded dirty gloves, she did not perform hand hygiene, she donned clean gloves. CNA B used several wipes to clean resident#3' buttocks. CNA B did not change gloves, she applied the clean brief and she continued with dressing the resident. In an interview on 09/19/23 at 10:45 AM, CNA B stated she was to wash hands before and after care. CNA B also stated she was supposed to change gloves and complete hand hygiene after removing the dirty gloves. CNA B stated she did not complete hand hygiene or change gloves after cleaning the resident because she forgot. CNA B stated she was supposed to change gloves and complete hand hygiene to prevent the spread of infection. In an interview on 09/21/23 at 02:33 PM, the DON stated during incontinent care the staff were to complete hand hygiene before and after care. The DON also stated in between care CNA was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection. Record review of the facility policy titled Hand Hygiene, revised June 2020, reflected Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedures: . Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to . viii. After removing personal protective equipment . 675702 Page 5 of 5