Health inspection·July 22, 2022

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record review of the job titled Food Services Supervisor, revised 07/2016, revealed under Qualifications, Graduation from a course in food service supervision which meets the standards established by the American Dietetic Association or a graduate of another course in food service supervision with 90 or more hours in classroom instruction with on-the-job counseling by a dietician. Record Review of Employee List dated 7/18/2022 revealed no employee listed in the Food Service Supervisor position. Record review of undated, untitled department head list revealed Food Service Supervisor position blank In an interview on 07/22/22 at 9:12 AM [NAME] C stated, we don't currently have a dietary manager. We have been without one for about 3 months or so. I know what it takes to be one, I'm thinking about doing it, but i am nervous. I like being a cook. I have 3 times a day to make these folks day and hearing that my food was good, is what i look forward to most. In an interview on 07/22/22 at 9:23AM Administrator A stated, I don't have a Dietary Manager currently. I don't know that I've been written up on that yet. I am aware I have to have one. I can't believe I paid for the previous girl to get her certification and she left. We have ads out everywhere for help in the kitchen. Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 7/22/22, revealed all residents in the facility received meals and snacks served from the kitchen. Page 1 of 4 675740 675740 07/22/2022 Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to maintain an infection control program to provide an environment to help prevent the development and transmission of disease and infection for 1 of 1 resident (#17) reviewed for infection control practices in that: Residents Affected - Few Registered Nurse - F used an ungloved hand to retrieve a pill that fell out of the plastic medication cup when it was removed from the blister pack, then administered to the resident. This deficient practice could affect residents who receieve a medication from a blister pack requiring removal of the medication from a blister pack, thus resulting in the spread of infection. The findings were: Observation on 07/27/2022 at 8:15 AM of Registered Nurse - F retrieved a pill that fell out of the plastic medication cup when it was removed from the blister pack. The medication was a Methadone (Methadone is a powerful drug used for pain relief) pill. In an interview on 7/21/2022 at 8:15 AM Registered Nurse F,stated she had used hand gel prior to preparing the retrieval of the medication for resident #17. In an interview on 7/22/2022 at 11:45 AM the Director of Nurses (DON) stated there was no excuse for Registered Nurse - F's actions as she is aware of never touching any medication with ungloved hands. Record review of the facility policy on Medication Administration failed to state that medications should never be touched with bare hands. It failed to state what procedure to follow if a pill was dropped. The Director of Nurses stated a revision was due for several policies. The Medication Administration had no date on it. 675740 Page 2 of 4 675740 07/22/2022 Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on interview and record review, the facility failed to conduct regular inspection of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 5 of 5 residents reviewed for bed rails assessments. The facility failed to have a maintenance program to conduct regular inspections of the beds and bedrails to identify risks and problems. This failure could place residents with bed rails at risk of entrapment, injury, or death. The findings were: Observation on 07/22/22 at 10:34 AM revealed Resident #2 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/19/22 at 01:25 PM revealed Resident #16 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/22/22 at 10:24 AM revealed Resident #15 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/22/22 at 10:35 AM revealed resident #28 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/21/22 at 10:37 AM revealed resident #25 had bed rail (assist/grab bar) on both left and right side of bed in the up position. In an Interview on 07/21/22 at 10:31 AM with facility Maintenance E & D stated they were not aware of monitoring any bed rails. Maintenance E states he has never done it before. In an interview on 07/22/22 at 12:33 p.m. Maintenance D stated he did not have the manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds. In an interview on 07/21/22 at 03:04 PM with Maintenance D, he stated that all resident beds were checked and that there were 4 bed rails loose. He went on to state that he tightened all 4 bed rails. In an interview on 07/21/22 at 04:00 PM with Administrator, she states that they do not have a policy where each bed rail is checked preventatively. When asked if they have a preventative maintenance program or anything that would ensure the bed rails are checked and the frequency at which they are checked, she replied no we don't, but we should. In an interview with the Minimum Data Set Coordinator on 07/21/22 at 04:37 PM, she stated the term restraint was used for bed rails. She added the facility is not using bed rails as a restraint device. The bedrails are used as assist devices for the resident's ability to move in the bed or assist to get in or out of bed. In an interview on 7/22/2022 at 9:15 AM, the two maintenance employees (E and D) who work jointly 675740 Page 3 of 4 675740 07/22/2022 Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many in the facility stated they had not been checking the bed rails for safety to assure the bedrails were not loose. There was no set routine to inspect the bed rails. The two maintenance employees (E and D) who work jointly in the facility stated they did not know if the manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds were still available. In an interview on 7/22/2022 at 10:40 AM., the Administrator stated the beds in the facility came with the enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and to hang the bed remote control on. The Administrator stated if the enabler bars were ¼ bars then they would be considered bed rails, but they were enabler bars. The Administrator did not state how the facility monitors the enabler bars (assist/grab bars/bed rails) to ensure they are correctly installed on the bed. Center for Devices and Radiological Health's Guidance for Industry and FDA Staff Hospital Bed System Dimensional and assessment Guidance to Reduce Entrapment issued 3/10/2006, pages 13-17, revealed the space between the bed rail and mattress was a potential zone of entrapment. The FDA is recommending a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside surface of the rail and the compressed mattress. Record review of the facility's undated policy Use of Siderails revealed Each resident shall be provided with a hospital type bed which includes two side rails, both in good working order. The resident has the right to be free from any siderail device which would restrict their freedom of movement imposed for purposes of discipline or staff convenience and not required to treat medical condition Whenever a siderail is used as a restrain, the nursing staff will determine through a comprehensive written assessment, that the siderails are necessary to assist the resident in attaining or maintaining their highest practical physical, mental and psychosocial wellbeing the same procedures will be followed for siderails that are followed as previously mentioned for the restraints. The facility had no policy for bed safety to address checking of bedrails on a routine basis. 675740 Page 4 of 4