Health inspection·August 9, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to implement its written polices, and procedures that prohibit abuse, neglect and exploitation for 10 of 16 staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B) reviewed for neglect and abuse policies . Residents Affected - Some The facility failed to conduct annual EMR/NAR screening for staff. This failure could put residents at risk of receiving services from employees who with a history of misconduct and/or were ineligible to provide services in this setting. Finding include: Record review of personnel files revealed the following staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B) did not have current annual screening of the employee misconduct registry/nurse's aide registry completed: Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B. Interview on 08/09/23 at 9:52 AM with the Secretary stated she was of responsible for completing the annual EMR/NAR screenings. The Secretary stated it was mandatory to conduct annual screenings for EMR/NAR by the state. The Secretary stated the reason screenings are conducted was so staff are eligible to keep an eye on the residents and to ensure the residents are not being abused or neglected by the staff. The Secretary stated not keeping up with the annual mandatory screenings could be a risk to the residents leaving them open to abuse or neglect. The Secretary stated she keeps forgetting to do the annual screening for EMR/NAR and this years was completed on 08/08/23 for the staff. The Secretary stated the Administrator was responsible for overseeing that she was doing the annual mandatory screening. Interview on 08/09/23 at 3:55 PM the Administrator who stated that facility employees are screened for EMR/NAR upon hire and annually. The Administrator stated the purpose of screening annually was to make sure nothing had changed with any employee and that they are still eligible to work for the facility. The Administrator stated there could be a risk if screening was not done annually. The Administrator stated there was potential for abuse and neglect . Record review of the facility employees (Dietary Supervisor Date of hire 09/14/16, Activities Director Date of hire 11/14/16, CNA D Date of hire 06/08/21, CNA E Date of hire 01/14/20 , CNA F Date of hire 10/24/17, CNA H Date of hire 03/29/22, CMA K Date of hire 09/28/18, CMA L Date of hire 08/07/19, [NAME] B Date of hire 09/07/07). for EMR/NAR documentation revealed the EMR/NAR screening was conducted on 08/08/23. Page 1 of 18 675768 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0607 Record review of the facility abuse, and neglect policy dated 09/01/14 revealed employee misconduct registry - all personnel will go through the employee misconduct registry before hire and yearly thereafter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675768 Page 2 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #9's that reflected as needed oxygen therapy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #30's face sheet dated 08/09/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #30's history and physical dated 05/03/23 revealed a [AGE] year-old female diagnosed with chronic obstructive pulmonary disease, general weakness, and dementia. Resident #30's significant change MDS dated [DATE] revealed a diagnosis of asthma/ chronic obstructive pulmonary disease, muscle weakness, and history of covid-19. Resident marked down for oxygen therapy. Resident #30's care plan dated 01/06/23 revealed resident was on oxygen therapy for poor oxygen absorption. Oxygen via nasal cannula at 2 liters per minute continuous. Resident #30's order recap dated 03/29/23 revealed supplemental oxygen at 1 liter per minute by nasal cannula as needed as tolerated to keep oxygen saturation 92% or above every shift . Interview on 08/09/23 at 2:01 PM with the ADON. The ADON stated she did not know much about care plans. The ADON stated the doctors' orders needed to match the care plan. Interview on 08/09/23 at 3:20 PM with the DON stated she completed the care plans for the residents. The DON stated she oversees that the care plans are being completed correctly. The DON stated Resident #30 had doctors' orders for oxygen as needed oxygen. The DON stated the care plans were not correct because it did not reflect the doctors' orders. The DON stated, we go by doctors' orders. Record review of the facility care planning - interdisciplinary team policy dated 2014 revealed our facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care planning/interdisciplinary team were responsible for the review and updating of care plans. Record review of facility's using the care plan policy dated 2006 revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who 675768 Page 3 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0656 Level of Harm - Minimal harm or potential for actual harm have responsibility for providing care or services to the resident. Changes in the resident's condition must be reported to the MDS assessment coordinator so that a review of the resident's assessment and care plan can be made. Residents Affected - Few 675768 Page 4 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards for 1 (Resident #9) of 20 residents and to ensure 7 of 10 facility rooms were safe from hazards reviewed for accident hazards. 1. The facility failed to ensure that 5 resident-use bathroom sinks had hot water temperatures below 110 degrees F and did not put residents at risk of injury. 2. The facility failed to make sure the Resident #9's fall mat was placed according to plan of care 3. The facility failed to ensure that 1 utility closet and 1 housekeeping storage room remained closed/locked due to chemicals being stored in the housekeeping room and industry equipment/pipes in the utilizes closet. These failures could place residents at risk of injury. Findings include: Water Temperatures Observation on 08/07/2023 at 9:30 AM in the resident-use bathroom between rooms 14/16 using surveyor's thermometer revealed a hot water temperature of 127 degrees F. In observation and interview on 08/07/23 beginning at 10:15 AM the Maintenance Supervisor said two of five hot water heaters supplied hot water to the resident-use bathrooms on the facility's two wings (East Hall and [NAME] Hall). He said that the hot water heater for the [NAME] Hall provided hot water for all bathrooms on the [NAME] Hall and a communal shower located near the [NAME] Hall nurse's station. He said the hot water heater located to the right of the Administrator's office provided hot water for all the bathrooms and communal shower located in the East Hall. He said three other hot water heaters provided hot water to the laundry and kitchen only. Observation by the Maintenance Supervisor and surveyor of the resident-use bathroom sink between rooms [ROOM NUMBERS] (West Hall) revealed a hot water temperature of 118 degrees F using the Maintenance Supervisor thermometer. Observation by the Maintenance Supervisor and surveyor of the sink in the bathroom next to room [ROOM NUMBER] (West Hall) revealed a hot water temperature of 118 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor said that he checked water temperatures in the resident-use bathrooms for the whole facility every week and recorded the temperatures on a written log. Observation of the hot water temperature in the sink in a communal bathroom to the left of room [ROOM NUMBER] (West Hall) revealed a water temperature of 157 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor stated that the water temperatures might be high because morning baths had been done for some time. He said that typically when the showers were in use earlier in the morning all the hot water got used up so water temperatures would go down all over the facility. Observation of the sink in the private bathroom in room [ROOM NUMBER] (West Hall) revealed that there was no hot water because the hot water valve under the sink was off. The Maintenance Supervisor opened the hot water valve, and the hot water in the sink measured 130 degrees F using the Maintenance Supervisor thermometer. The Maintenance Supervisor was observed turning off the hot water valve saying that the water was too hot. 675768 Page 5 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In observation and interview on 08/07/23 at 10:27AM with the Maintenance Supervisor the [NAME] Hall hot water heater gauge reflected a hot water temperature of 141 degrees F. Maintenance Supervisor said the water was too hot and he would have to drain the hot water heater. In observation and interview on 08/07/23 at 10:34 AM with the Maintenance Supervisor the East Hall hot water heater gauge reflected a hot water temperature of 100 degrees F. In observation on 08/07/23 at 10:42 AM with the Maintenance Supervisor of the hot water from the sink in the East Hall bathroom for room [ROOM NUMBER] revealed a hot water temperature of 130 degrees F. In an interview on 08/07/23 at 10:59 AM the ADON said she had not received any complaints about resident-use water being too hot. She said that there were no incidents of scalding or burns from hot water for the past year. She said if CNAs noticed the water was too hot the nurse would be notified, and it would be reported to the facility Administrator. She did not know if there was a schedule for Maintenance to check water temperatures in resident bathrooms. Incident reports for the past six months were requested. Record review of incident reports dated from February to August of 2023 revealed no incident reports for burns or scalding. In an interview on 08/07/23 at 11:05 AM the DON was informed of the hot water temperatures being observed in resident use areas. She stated she did not know what the top water temperature for resident use should be, but that if the water temperature was too high residents could get scalded. In an interview on 08/07/23 at 12:03 PM the Maintenance Supervisor said he was draining the hot water heater for the [NAME] Hall and would set it at 100 degrees F. He stated he would also drain the East side hot water heater since there were rooms on the East side with high water temperatures. Water temperature logs for the past six months were requested. Record review on 08/07/2023 of the facility document Weekly Hot Water Temps 2023 dated from 01/02/2023 to 05/29/2023 documented that hot water temperatures were being checked once a week in all resident rooms. The document revealed no instances when the water temperature was higher than 103 degrees F. The document noted Safe water temperature between 100 [degrees] F - 110 [degrees] F. There were no water temperatures documented for the months of June 2023, July 2023 or August of 2023. In an interview on 08/07/23 at 5:03 PM the Administrator said that around 10:00 AM the facility had lowered the temperatures on both hot water heaters to lowest setting and drained hot water from both hot water heaters. In observation on 08/07/23 beginning at 5:09 PM with the Administrator and Maintenance Supervisor observation in the resident-use sink in the bathroom between Rooms 14/16 (West Hall) revealed a hot water temperature of 126 degrees F. Observation of the resident-use sink in communal shower room for the [NAME] side revealed a hot water temperature of 137 degrees F. Observation of the resident-use sink in room [ROOM NUMBER] (East Hall) revealed a hot water temperature of 118 degrees F. In an interview on 08/07/23 at 5:28 PM the Administrator and Maintenance Supervisor said they had called a plumber to inspect and adjust hot water heaters in the morning . 675768 Page 6 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 08/07/23 at 5:31 PM the ADON said excessive hot water temperatures could put residents at increased risk of scalding and burns. She said she had in-serviced all CNAs to check water temperatures on their bare skin, then have the residents also check the water temperature before using the water for resident care. Observation and interview on 08/08/2023 at 8:16 AM with the Maintenance Supervisor and the facility President (Co-owner) in the bathroom between rooms [ROOM NUMBERS] (West) revealed that the hot water temperature in the sink was 120 degrees F. The facility President stated there were several ways to adjust the hot water temperature and that water temperature at the point of use would be 4 to 6 degrees lower than the temperature showing on a hot water heater gauge. Observation and interview on 08/08/2023 at 8:26 AM with the Maintenance Supervisor, the facility President (Part Owner) and the Administrator in room [ROOM NUMBER] (East) revealed that the hot water temperature was 118 degrees F using the Maintenance Supervisor thermometer. The Administrator said that the plumber had determined that the temperature gauge on the East side water header heater was broken and stuck at 100 degrees F. He said that the East side water heater was currently set on hot. In observation and interview on 08/08/2023 at 11:22 AM a plumber and the Maintenance Supervisor were observed working on the East side water heater. The plumber said the water heater was set at low which would yield a maximum water temperature of 120 degrees. When asked he said that he had not been advised as to the acceptable temperature for hot water for the facility. He explained that the mixing valve on the water heater could be adjusted to mix hot and cold water to the desired temperature. In observation on 08/08/2023 beginning at 2:52 PM with the Maintenance Supervisor and Administrator, six resident-use bathroom sinks on the [NAME] Hall had hot water temperatures below 110 degrees F. It was observed that the resident-use bathroom sink in room [ROOM NUMBER] (East Hall) had a hot water temperature of 116 degrees F. The Administrator said that the hot water for room [ROOM NUMBER] went directly into the bathroom sink and did not pass through the water heater mixing valve. He said the occupant of room [ROOM NUMBER] wanted to stay in that room with the understanding that the hot water to the sink would be turned off. In an interview on 08/09/2023 at 8:11 AM the facility Administrator said the mixing valve on the East Hall water heater had been adjusted to lower the temperature of water delivered to resident's rooms. He did not state to what temperature the water temperature had been lowered. Record review of the undated facility policy Water Temperature documented it was the policy of the facility to maintain a water temperature suitable for the comfort of the residents in resident-use areas. It stated to check temperature in resident's room, shower and restroom. Water temperature must not be higher than 110 degrees Fahrenheit. Temperature log must be done at least once a week by maintenance. Fall Risk Resident #9's face sheet dated 08/09/23 revealed admission on [DATE] to the facility. Resident #9's history and physical dated 03/08/22 revealed an [AGE] year-old female diagnosed with dementia, debility (physical weakness), spondylosis (abnormal wear on the cartilage and bones of the neck (cervical vertebrae)), aspiration pneumonia, and dysphagia (difficulty swallowing). 675768 Page 7 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0689 Level of Harm - Minimal harm or potential for actual harm Resident #9's quarterly MDS dated [DATE] revealed ADLs for resident for bed mobility was one person assist with total dependence and transfers as total dependence with two-person assistance. Resident #9's care plan dated 02/03/23 revealed the resident was low risk for falls due to dementia and limited mobility. Place the floor mat to minimize the injury in case resident falls. Residents Affected - Some Resident #9's quarterly fall risk assessment for 02/05/23 indicated resident was a high risk for falling and had a history for falling before. Resident's gait was weak and impaired. Fall risk assessment dated [DATE] revealed low risk for falling and was marked as no for history of falling . Observation on 08/09/23 at 1:16 PM revealed Resident #9 was in bed with head of bed elevated past the headboard top plane and floor mat was underneath the resident's bed. Observation on 08/09/23 at 2:13 PM in Resident #9's room. The resident's floor mat was underneath the resident's bed while resident was lying in bed. Interview on 08/09/23 at 1:20 PM RN A stated Resident #9's fall mat needed to be placed next/near the resident's bed and not underneath Resident #9's bed so if resident fell she would not get hurt. RN A stated anyone placing the resident in bed was responsible for putting the fall mat back in place next to the bed. RN A stated the risk to Resident #9 was falling possibly getting fractures because she was older and had brittle bones. Interview on 08/09/23 at 2:01 PM with the ADON. The ADON stated Resident #9 was not high risk for falls. The ADON stated Resident #9 has never had a fall during her time at the facility. The ADON stated the fall mat needed to be placed back next to the bed so if the resident fell she would not get hurt. The ADON stated Resident #9 would be at risk for injuries since the fall mat was not placed correctly. Utilities Closet & Housekeeping Storage Room Observation on 08/07/23 at 4:55 PM revealed the in the main corridor hallway in the building, the utilities closet was not closed all the way shut. By pulling the door it opened and inside was a water heater, a ladder, boiler, piping on the walls, and other large industry appliances with metal piping running down at ankle level running through the room. The utilities closet was located in a high traffic area where residents were passing by. Interview on 08/07/23 at 4:47 PM the ADON stated the utilities room needed to be secured, closed, and locked due to the water heater and other industrial equipment being housed in the room. The ADON stated it was to be closed and locked so resident would not get into the room. The ADON stated there was a risk to the residents because there was a water heater, boiler, and other appliances in the room in which the residents could have hurt themselves with. Observation on 08/07/23 at 5:03 PM revealed in the main corridor on the other side of the hallway in the building the housekeeping storage room was left open. Inside the room there were various chemicals in spray bottles and containers, brooms, mops, boxes. Interview on 08/07/23 at 5:05 PM the ADON stated the housekeeping door needed to remain closed and 675768 Page 8 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some locked so residents don't get in. The ADON stated the risk to the residents where that they could get the chemicals risking injury. Interview on 08/08/23 at 1:25 PM with the Dietary Supervisor stated he was also in charge of the housekeeping department. The Dietary Supervisor stated the housekeeping storage room door was not supposed to be opened and unlocked. The Dietary Supervisor stated there was a risk to the resident if they got into the room if they ingested any of the chemicals. Interview on 08/08/23 at 1:45PM AM the Maintenance Supervisor stated the utilities closet needed to be closed and locked at all times. The Maintenance Supervisor stated it was a hazard for the residents because there was industrial appliances in the room and pipes were low to the ground. The Maintenance Supervisor stated if the residents had gotten into the room they could have fallen or gotten hurt. Interview on 08/09/23 at 3:55 PM with the Administrator stated the utilities closet and housekeeping storage room were to remain closed and locked. The Administrator stated they were putting locks at the top of the doors to make sure they locked and where residents were not able to reach them. The Administrator stated the residents going into the utilities or housekeeping rooms could be a risk of something dangerous happening to them. The Administrator stated the facility employees are responsible for making sure that the doors are closed and locked for the utilities and housekeeping rooms. Facility policy of accidents and supervision and falls were not obtained. Record review of the facility dietary safety awareness policy not dated revealed to keep bathroom doors and utility doors closed. 675768 Page 9 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 who is fed by enteral means receives the appropriate treatment and services for 1 of 10 residents (Resident #9) reviewed for enteral feeding. Resident #9 was on continuous feeding and while feeding. The facility failed to ensure Resident #9's head of the bed was elevated at a 45-degree angle per care plan These failures could place residents receiving enteral feedings at risk of aspiration. Findings include: Resident #9's face sheet dated 08/09/23 revealed admission on [DATE] to the facility. Resident #9's history and physical dated 03/08/22 revealed an [AGE] year-old female diagnosed with dementia, debility (physical weakness), aspiration pneumonia, and dysphagia (difficulty swallowing). Resident #9's care plan not dated revealed feeding tube - resident has an alteration in gastro-intestinal status with dysphagia. Avoid lying down for at least one hour after PEG (percutaneous endoscopic gastrostomy) feeding. Keep HOB (head above bed) elevated at all times. Resident #9 requires tube feeding due to dysphagia and requires/needs the HOB (head above bed) elevated 45 degrees during and thirty minutes after tube feeding. Observation on 08/08/23 at 4:30 PM of Resident #9 in bed with HOB top of mattress level with the plane of the headboard indicating level of bed was low and not at 45 degrees. Observation on 08/09/23 at 1:16 PM of Resident #9 in bed with head of bed elevated past the headboard top plane indicating 30 degrees. Interview and observation on 08/09/23 at 12:03 with RN A revealed she administered 120ml (mililter) water bolus to Resident #9 as scheduled via G-tube . Resident #9 was lying in bed with head of bed slightly elevated. When RN A completed administration of water bolus Resident #9 was left with head of the bed slightly elevated. RN A stated head of bed needed to be at about a 30-degree angle. RN A stated the head of the bed and mattress where at the same level indicating the resident was in a 30-degree angle . RN A proceeded to elevate the head of the bed to a 40-45-degree angle. RN A stated resident needed to be with the head of the bed at a higher angle to prevent aspiration at 45 degrees. Interview and observation on 08/09/23 at 1:20 PM RN A stated that earlier Resident #9 was too low in her bed and was not elevated according to doctors' orders. At 1:27 PM Resident #9 was in bed and a range scale was applied to the frame of the bed indicating 30 degrees. RN A stated that Resident #9 was not elevated correctly as she needed to be 45 degrees as per doctors' orders. RN A stated not having the resident at 45 degrees can be a risk for her. RN A stated the Resident #9 could aspirate. Record review of facility tube feeding policy not dated indicated elevate HOB (head above bed) 675768 Page 10 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0693 30-45 degrees to prevent aspiration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675768 Page 11 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #30) of 4 residents observed for oxygen management. Residents Affected - Few Resident #30 was on oxygen which did not have an oxygen sign posted outside of her bedroom. Resident #30 was outside in the front patio of the facility with an oxygen tank that was in the red indicating refill oxygen. These failures could place residents on oxygen therapy at risk of an explosion or fire, injury, incorrect or inadequate oxygen support, and decline in health. Findings include: Resident #30's face sheet dated 08/09/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #30's history and physical dated 05/03/23 revealed a [AGE] year-old female diagnosed with chronic obstructive pulmonary disease, general weakness, and dementia. Resident #30's significant change MDS dated [DATE] revealed a diagnosis of asthma/ chronic obstructive pulmonary disease, muscle weakness, and history of covid-19. Resident was marked down for receiving oxygen therapy. Resident #30's care plan dated 01/06/23 revealed resident was on oxygen therapy for poor oxygen absorption. Oxygen via nasal cannula at 2 liters per minute continuous. Resident #30's order recap dated 03/29/23 supplemental oxygen at 1 liter per minute by nasal cannula as needed as tolerated to keep oxygen saturation 92% or above every shift. Observation on 08/07/23 at 9:43 AM revealed Resident #30's oxygen tank hanging of the back of the wheelchair was on red and had no oxygen. There was an oxygen concentrator in Resident #30's room and resident was not using the oxygen at that moment. No oxygen sign was posted outside of resident's room. Observation on 08/08/23 at 9:54 AM revealed Resident #30's room did not have an oxygen sign posted outside of the bedroom. Resident #30 was not in her room. One oxygen tank was in the corner of the room and indicated green, meaning it had oxygen. Interview on 08/08/23 at 10:11AM with RN A stated oxygen signs state that oxygen was being used by a resident in the room. RN A stated oxygen signs also lets everyone know not to smoke. RN A stated the facility had the signs up and they were remodeling the hallway and forgot to put them back up . RN A stated the nurses notify the Director of Nursing that they need an oxygen sign for the residents who are on oxygen. RN A stated not having oxygen signs posted in rooms where residents are using oxygen can be a risk for the residents. RN A stated the risk could be an explosion. RN A stated no residents in the facility have oxygen signs posted and the risk still exists. 675768 Page 12 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/08/23 at 10:20 AM the ADON stated oxygen signs mean that a resident was using oxygen. The ADON stated it meant precautions of no smoking. The ADON stated the risk to the resident of not having oxygen signs posted was an explosion. The ADON stated since they are remodeling the halls it was the maintenance and nursing department responsibility to ensure the oxygen signs were posted. Observation on 08/08/23 at 10:32 AM - revealed Resident #30 was outside in the front patio area of the building in her wheelchair. Resident #30 had an oxygen tank in the back of her wheelchair. The meter read arrow was on red indicating the tank was empty. Resident #30 was not seen having breathing problems. Observation and interview on 08/08/23 at 10:38 AM the ADON observed Resident #30 sitting in her wheelchair outside in the front patio area. Resident #30's oxygen tank was on red. The ADON stated that the arrow on red indicated that the oxygen tank was empty. The ADON stated it was the nurse's responsibility for ensuring the residents tanks are full. The ADON stated there could a be a risk to Resident #30 if she needed oxygen. The ADON immediately requested for a replacement oxygen tank and took the resident back to the room. Interview on 08/08/23 at 4:02 PM with the ADON stated the DON had notified her that oxygen sign postings were not required outside of the resident bedrooms because the facility was a no smoking facility and was not required. Record review of facility emergency preparedness (facility Disaster Plan) policy not dated revealed storage and use of oxygen must have an oxygen sign posted. 675768 Page 13 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post required nurse staffing information in a prominent place readily accessible to resident and visitors Residents Affected - Many The Facility failed to ensure nurse staffing information was posted. This failure could put staff, residents, and resident representatives at risk of being unaware of actual staffing levels and available staff. Findings include: Record review on 08/08/23 at 3:47 PM - revealed that 29 of 54 staff posting sheet reviewed indicated blanks (numbers of staff and census) and some were not filled out completely. Interview on 08/08/23 at 3:04 PM with the ADON stated she was responsible for filling out the staff posting sheet. The ADON stated she checks on the staff posting sheet daily and the weekend Supervisor checks on them on the weekends to make sure they are completely filled out. The ADON stated some of the staff posting sheets are double weekends but does not know why the other staff posting sheet were not filled out. The ADON stated the purpose of the staff postings was for staff to know where they were going to be at, the resident load, and if staff needed assistance they knew when they could get help from. The ADON stated the staffing posts were also available to whoever wanted to see them and if they had any questions. The ADON stated staffing are trained during orientation on how to fill them out. The ADON stated there was no risk to the residents if they were not filled out properly. Record review of facility required postings policy not dated revealed procedure of nursing staff information. Nothing further was documented. 675768 Page 14 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation/storage, in that: 1. Foods in dry store, walk in, and freezer were not dated or labeled properly. 2. Food containers and food bags were not properly sealed in the kitchen and walk-in. 3. Hot food had been placed in the refrigerator while hot. 4. A dented can was not removed from shelf rotation. 5. the dish washer temperature was not at or above 140 degrees. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 08/07/23 beginning at 8:15 AM with the Dietary Supervisor revealed in the freezer door was a bag of Chile rellenos with no expiration date noted. On the first shelf in the freezer there labeled. At 8:32 AM on in the seconded freezer on the door was a closed bag of chicken nuggets not labeled, underneath on the door were French toast packages not labeled. At 8:41 AM in the refrigerator on the seconded shelve was a small metal pan labeled breakfast and not labeled correctly and very hot. The Dietary Supervisor stated the hot pan of breakfast puree was not to be in the refrigerator and needed to cool down first before being put in to the refrigerator. On the right side of the refrigerator on the top shelve was a container of orange juice not labeled correctly , an open bag of cheddar cheese slices in a zip lock bag and not labeled correctly, a zip lock bag that was not sealed properly of white cheese and not labeled correctly. At 8:45 AM across the refrigerator and freezer the shelves had a container of creamy of wheat that was open and not sealed. The Dietary Supervisor stated the creamy of wheat had to be sealed or closed to prevent cross contamination. Observation and interview on 08/07/23 at 8:50 AM in the basement revealed there was a dented can of pears in the rotation shelves. The Dietary Supervisor stated the dented can of pears should not have been placed in the rotation shelves and should have been placed in the discarded box to return to the supplier. The Dietary Supervisor stated dented cans are not used because they are contaminated, grow bacteria like e-coli and if served to residents can hurt their stomachs. All the cans on the 675768 Page 15 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0812 shelve were not dated. Level of Harm - Minimal harm or potential for actual harm Observation on 08/07/23 at 9:00 AM in the kitchen in the prep area were two spice containers (Lemon pepper & Black pepper) that has the lids open. The Dietary Supervisor stated the lids need to be closed to prevent bugs from going into the containers and causing contamination. Residents Affected - Some Observation on 08/08/23 at 8:55 AM of the dish machine temperature gauge for the water as dishes were moving through it read 128 degrees F indicating the water was not being heated to 140 degrees F. Interview on 08/08/23 at 9:04 AM with [NAME] B stated she waits for cooked foods to cool down before putting them in to the refrigerator. [NAME] B stated the hot foods are not supposed to go into the refrigerator hot. [NAME] B stated if served to the residents it could hurt their stomachs. [NAME] B stated open foods need to be labeled correctly with date, name, and expiration date. [NAME] B stated the dish machine's water needed to be at 140 degrees to be able to kill the germs. [NAME] B stated not being at 140 degrees runs the risk of germs not being killed. [NAME] B stated she lets her supervisor know if there are any dented cans. [NAME] B stated she does not use dented cans because it can cause e-coli. [NAME] B stated at her house she does not use dented cans because of bacterial growth that can get you sick. [NAME] B stated the residents could get sick if served. Interview on 08/08/23 at 9:20 AM with the Dishwasher C stated foods need to be labeled correctly with name, date, and expiration date. Dishwasher C stated she received training with temperature, labeling, and cooking foods from her Dietary Supervisor as well as through the food handler's course. Dishwasher C stated the water in the dish machine needed to be at 140 degrees to kill the bacteria and if it was not at 140 then it would not kill the bacteria. Dishwasher C stated running dishes through the dish machine not at 140 degrees and using the dishes could get resident's sick. Dishwasher C stated if she sees dented cans, she notifies her Dietary Supervisor. Dishwasher C stated dented cans are not good to use but does not know why they are not good to use. Interview on 08/08/23 at 9:38 AM the Dietary Supervisor stated that they do not put an expiration date on foods because they know that the food will not last pass seven days. The Dietary Supervisor stated mislabeled foods that are served to residents can get them sick. The Dietary Supervisor stated dented cans cannot be used because organisms can grow inside of the can . The Dietary Supervisor stated the dish water needed to be at 140 degrees to be able to kill the bacteria and not being at that temperature could get resident's sick. Recorded review of the facility dietary policies/procedures not dated revealed food storage - open food items must be dated when opened. Open frozen foods must be dated. Use dishwashing machine to wash utensils at 140-degree temperature. Record review of the facility dietary safety awareness policy not dated revealed outdated, dented goods must be discarded. Record review of facility in-service report on diet and nutrition dated 05/12/23 revealed dietary staff were trained with the understanding the importance of nutrition care. Record review of facility in-service report for food temperatures dated 06/24/23 revealed dietary staff were trained on people review and learn to drive the correct and different kind of temperature on the food. 675768 Page 16 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 1 of 1 (Dumpster) garbage dumpster containers reviewed for food safety requirements. Residents Affected - Few 1. One dumpster in the back alley of the facility had trash on the floor outside and around the dumpsters. 2. One dumpster had its lid open. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided an unsafe, unsanitary and uncomfortable environment. Findings include: Observation and Interview on 08/07/23 with the Dietary Supervisor beginning. at 8:18 AM revealed one dumpster had both side lids open exposing the trash. The Dietary Supervisor stated the maintenance department handles the trash outside. The Dietary Supervisor stated anybody throwing the trash had to close the lids after throwing the trash. The Dietary Supervisor stated the lids need to be closed due to contamination. At 8:23 AM on the right side of the dumpster was a paint can, plastic water bottle, and varies other pieces of trash on the floor. Behind the dumpster was a brown cardboard box, napkins, plastic waters bottles in the edges of the concrete floor mixed with vegetation and other unidentifiable pieces of trash. The Dietary Supervisor stated if trash was on the floor around the dumpster, they did not have to let maintenance know because maintenance was always outside cleaning. The Dietary Supervisor stated not picking up the trash that was on the floor around the dumpster and closing the dumpster lids would attract animals and pests. Interview on 08/07/23 at 11:16 AM the Maintenance Supervisor. stated the kitchen was responsible for the dumpster outside. The Maintenance Supervisor stated maintenance was responsible for everything within the facility fence. The Maintenance Supervisor stated the city goes out to clean the alley way once in a while. The Maintenance Supervisor stated that the dumpster lids needed to be closed after the trash was thrown and then picked up by whoever saw it. The Maintenance Supervisor stated trash on the floor and the lids open could attract animals like cats and be an infection control issues. Interview on 08/08/23 at 9:04 AM [NAME] B stated when throwing out the trash in the dumpster the dumpster lids need to remain closed. [NAME] B stated it was so the trash did not come out of the dumpster and contaminate the area round the dumpster. [NAME] B stated the lids were to remain closed to not attract animals. [NAME] B stated maintenance was responsible for picking up the trash area the dumpster area but if she saw trash, she would pick it up. Interview on 08/08/23 at 9:20 AM Dishwasher C stated when throwing trash, they must keep lids closed. Dishwasher C stated she does not know why the dumpster lids need to be closed but it had always been done that way. Dishwasher C stated if she saw trash on the floor, she would pick it up. Dishwasher C stated the trash on the floor would attract animals and would breed bacteria. 675768 Page 17 of 18 675768 08/09/2023 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/08/23 at 9:38 AM the Dietary Supervisor stated the trash bags needed to be tied well and thrown in the dumpster with the dumpster lids closed. The Dietary Supervisor stated the lids being opened attracted animals. The Dietary Supervisor stated if he sees harmless trash, he picks it up and if not, they let maintenance know to go pick it up. Record review of the facility environmental services policy not dated revealed area around dumpster shall be kept clean to ensure that the dumpster can be accessed by both employees and waste disposal company. 675768 Page 18 of 18