Health inspection·September 12, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #3 and Resident #32) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #3 and Resident #32 with respect and dignity, with staff removing residents' trays prior to being completed. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. The findings included: Resident #3 Record review of Resident #3's face sheet dated 09/12/2024 revealed an [AGE] year-old male admitted on [DATE], with the following diagnoses: Vitamin-D deficiency, type 2 diabetes, constipation, mood disturbance, and chronic kidney failure. Record review of Resident #3's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive impairment ). Resident #32 Review of Resident #32's face sheet dated 09/12/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses: type 2 diabetes, Vitamin D Deficiency, gastritis, and major depressive disorder. Record review of Resident #32's Comprehensive MDS dated [DATE] revealed that Section C- Cognitive Patterns had a BIMS score of 06 (severe cognitive impairment ). During an interview on 09/11/2024 at 2:30pm, CNA G stated she was in the dining room with CNA H at breakfast time. She stated CNA H pulled the unfinished tray from Resident #32. CNA G stated Resident #32 asked CNA H Why are you taking my tray if I'm not finished with it? CNA G stated that CNA H ignored Resident #32 and only brought him back a juice and half of a banana. CNA G stated at lunchtime, CNA H repeated her same actions, taking Resident #32's tray away from him prior to finishing, once again caused him to yell out for his food. CNA G stated she felt the resident was left hungry at the Page 1 of 22 675768 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0550 end of the day and also resulted in her 3-day suspension for taking up for a resident from the ADMN. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/12/24 at 10:18 AM Resident #3 stated he ate in his room. He stated staff often brought his trays and placed them on his table taking the top off without waking him up. Resident #3 stated his food would get cold and resulted in him not wanting to eat it. He stated at times staff would come in and take his tray away telling him the kitchen needed to clean the dishes before leaving at a certain time, which resulted in him not finishing his meals. Resident #3 stated that Resident #32 was his roommate and he had witnessed staff taking his food/tray away before he finished as well. He stated he had spoken to staff about this with nothing being done. Residents Affected - Some During an interview on 09/12/2024 at 11:57 AM the ADMN stated he had not known of this situation prior to this day. He stated all residents should be given enough time to eat everything that was provided on their plates and felt the CNA's would not have done that . During an interview on 09/12/2024 at 5:26 PM the Dietician stated that all residents have the right to be served and as well as given ample time to eat their food on their tray. She stated if the residents were not given enough time to eat what was provided, it could cause the resident to not get the nutritional value they needed. She stated it would have been the actions of the floor staff to monitor and oversee that the residents received and were given time to eat. She stated the ADMN should have monitored meal services as well. During exit conference on 09/12/2024 at 5:45 PM the facility stated they did not have a policy. 675768 Page 2 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accommodate residents needs and preferences and accommodation of needs, for 1 (Resident #2) of 13 residents reviewed for dignity. Residents Affected - Few The facility failed to ensure Resident #2's call light was within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Record review of Resident #2's face sheet dated 09/12/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia, anxiety disorder, hypertension (high blood pressure), and falls. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment. Section GG: Functional Abilities and Goals revealed Resident #2 required assistance with transfers and when out of bed did not ambulate on her own and was in wheelchair. Record review of Resident #2's most recent Care plan reviewed on 09/12/2024 revealed: Be sure her call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. During an observation on 09/10/24 at 11:30 AM, Resident #2 was laying in her bed. The call light was not within reach of Resident #2. The call light was hanging on the wall at the foot of Resident #2's bed. During an observation on 09/12/24 at 2:51 PM, Resident #2 was laying in her bed. The call light was not within reach of Resident #2. The call light was hanging on the wall at the foot of Resident #2's bed. During an interview on 09/12/2024 at 3:15 PM, the DON stated when a resident was in bed in their room, the call light should have been placed within reach of the resident. The DON stated the nursing staff and CNA's were responsible to ensure that call lights were in reach of residents. The DON stated residents might not have had their needs met if the call light was not within reach. The DON stated what led to the failure was staff forgetting to check to make sure the call light was within reach of resident when they left the room. During an interview on 09/12/2024 at 3:45 PM, the ADMN stated his expectation was that call lights be within reach of residents. The ADMN stated the DON was responsible to monitor staff to ensure call lights were within reach of residents. The ADMN stated the effect on resident's not having the call light within reach could have been resident could have fallen or not have their needs met in a timely manner. The ADMN stated staff not paying attention and/or forgetting to check call light placement could have led to failure of call light not being in reach. Record review of Call Lights not dated, revealed: Each resident will have a call light, Call light 675768 Page 3 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0558 will be placed within reach of resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675768 Page 4 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 2 (Resident #46 and Resident #198) of 13 residents reviewed for care plan completion. 1. The facility failed to complete Resident #46 and Resident #198's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #46's face sheet dated 09/12/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: chronic kidney disease, renal dialysis, hypertension (high blood pressure), and Type 2 diabetes. Record review of Resident #46's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns revealed Resident #46 had a BIMS score of 00, which indicated he had severe cognitive impairment. Record review of Resident #46's medical record revealed no evidence of the completion of a baseline care plan. Record review of Resident #198's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, pain, type 2 diabetes mellitus with diabetic chronic kidney disease (kidney disease resulting from type 2 diabetes), and malignant neoplasm of prostate (prostate cancer). Record review of Resident #198's admission MDS assessment dated [DATE] revealed: BIMS score of 07 which indication severe cognitive impairment. Record review of Resident #198's medical record revealed no evidence of the completion of a baseline care plan. During an interview on 09/11/2024 at 4:38 PM, the MDS Coordinator stated she was responsible for completing the baseline care plans and that baseline care plans were supposed to be completed within the first 24 hours of admission. The MDS Coordinator stated that what led to the failure of baseline care plans not being completed, within time frame, was that she had to work the floor sometimes and if she worked the floor over the weekend, she would take off during the week. The MDS stated when she worked the floor those duties took priority over her other duties, that was what caused the delay in completing baseline care plans. The MDS Coordinator stated she did not feel residents were affected by not having baseline care plans completed. During an interview on 09/12/2024 at 3:15 PM the DON stated the MDS coordinator was responsible for completing the baseline care plan. The DON stated she did not feel there was an effect on residents 675768 Page 5 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for not having a baseline care plan completed. The DON stated that staff don't look at the care plan, it was just more paperwork to complete. The DON did not provide a reason for the failure of baseline care plans not being completed. Record review of facility policy titled, Care Plans-Preliminary dated August 2006, revealed: To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatment, etc.), and implement a nursing care plan to meet the resident's immediate care needs. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 675768 Page 6 of 22 675768 09/12/2024 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 - Some 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 interviews and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #27, Resident #28, and Resident #36) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed Resident's code status and fall mat. The facility failed to ensure Resident #27's comprehensive care plan addressed Resident #27's code status and PASRR services. The facility failed to ensure Resident #28's comprehensive care plan was resident specific and person centered. The facility failed to ensure Resident #36's comprehensive care plan was resident specific and person centered. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #2 Record review of Resident #2's electronic face sheet dated 09/12/2024 revealed an [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia, anxiety disorder, hypertension (high blood pressure), and falls. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment. Section GG: Functional Abilities and Goals revealed Resident #2 required assistance with transfers and when out of bed did not ambulate on her own and was in wheelchair. Record review of Resident #2's physician orders dated 09/12/2024 revealed Resident #2 had a code status of DNR. Record review of Resident #2's most recent comprehensive care plan reviewed on 09/12/2024 revealed no evidence of Resident #2's code status or the use of a fall mat. During an observation on 09/10/2024 at 11:30 AM, Resident #2 was laying in her bed with the fall mat laying on the floor beside the bed. 675768 Page 7 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0656 Resident #27 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #27's electronic face sheet dated 09/12/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: type 2 diabetes, paranoid schizophrenia , major depressive disorder, and elevated blood pressure. Residents Affected - Some Record review of Resident #27's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 9, which indicated she had moderate cognitive impairment. Record review of Resident #27's physician orders dated 09/12/2024 revealed Resident #27 had a code status of DNR. Record review of Resident #27's PASRR Comprehensive Service Plan dated 11/14/2023 revealed Resident #27 received routine case management and training skills under PASRR services . Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of bones gradually wears away). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 meaning cognition was intact. Record review of Resident #28's comprehensive care plan last revised on 09/10/2024 revealed: Goal: Falls: the resident has had an actual fall with (SPECIFY: no injury, minor injury, serious injury) Unsteady gait Date .Interventions: The resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of depression, anxiety, or sadness) through the review date . Resident #36 Record review of Resident #36's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility most recently on 01/19/2024 with diagnoses to include: visual hallucinations, altered mental status, and insomnia. Record review of Resident #36's significant change MDS dated [DATE] revealed: BIMS score of 00 which indicated severe cognitive impairment. Record review of Resident #36's most recent comprehensive care plan reviewed on 09/12/2024 reviewed: Goal: ADL: The resident has an ADL self-care performance deficit r/t weakness. Intervention: BATHING/SHOWERING: The resident requires transfer assistance by (1) staff with (SPECIFY bathing/showering) 3 times a week and as necessary . During an interview on 09/11/2024 at 4:38 PM, the MDS Coordinator stated she was responsible for completing the comprehensive care plans. The MDS Coordinator state she did not think code status needed to be incorporated in the care plan because it was in the orders and there was flag on residents' electronic chart that stated code status of residents. The MDS Coordinator stated the DON was responsible to monitor the care plans. The MDS coordinator stated she did not feel the residents were affected by not having comprehensive care plans not being completed. The MDS Coordinator did not have a 675768 Page 8 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0656 response to what led to the failure . Level of Harm - Minimal harm or potential for actual harm During an interview on 09/12/2024 at 3:15 PM, the DON stated the MDS coordinator was responsible for completing the comprehensive care plan. The DON stated she did not feel that residents were affected by the missing information, that staff did not look at the care plans. The DON stated care plans were just more paperwork that had to be completed. The DON did not provide a reason for the failure of comprehensive care plans not being completed . Residents Affected - Some Record review of facility titled, Care Plans- Comprehensive dated December 2010, revealed Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; incorporate risk factors associated with identified problems; build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Identify the professional services that are responsible for each element of care. 675768 Page 9 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 5 (04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; 06/08/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's Direct Care Staff Daily Report from 04/01/2024 to 06/30/2024 revealed on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024 there was no evidence of RN coverage. During an interview on 9/12/2024 at 3:15 PM, the DON stated her expectation was to have RN coverage daily. The DON stated she was on call on weekends and can be contacted when there was not a RN working. The DON stated they have a RN that worked on the weekends and then her and the MDS Coordinator work Monday and Friday. The DON stated the MDS Coordinator filled in on the weekends when needed. The DON stated if there were dates on the weekends that were reported with no RN coverage, she did not work those weekend dates, but she would have been available by phone to come to pronounce if a resident had passed away. The DON stated she did not feel there was an effect to residents when there was no RN coverage. The DON stated what led to failure was not being able to hire additional RNs. During an interview on 9/12/2024 at 3:45 PM, the ADMN stated his expectation was to have 8 hours of RN coverage 7 days per week. The ADMN stated the DON was responsible for ensuring there were 8 hours of RN coverage daily. The ADMN stated the effect on residents was the discontinuity of care. The ADMN did not have a response to what led to the failure of not having 8 hours of RN coverage. Record review of facility policy titled; RN Coverage dated 06/26/24 revealed: It is the policy of facility to provide 7-day RN coverage. 675768 Page 10 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 of 6 residents (Resident #28 & Resident #198) reviewed for medication errors. Residents Affected - Some 1. The facility failed to ensure MA administered the correct dose of calcium and vitamin D to Resident #28 according to the physician orders. 2. The facility failed to ensure MA administered olmesartan medoxomil (for blood pressure) and amlodipine besylate (for blood pressure) to Resident #198 according to physician orders. These failures could place residents at risk of inadequate therapeutic outcomes. Findings included: Resident #28 Record review of Resident #28's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: osteoarthritis (when the cartilage that cushions and protects the ends of bones gradually wears away). Record review of Resident #28's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 meaning cognition was intact. Record review of Resident #28's comprehensive care plan last revised on 09/10/2024 revealed Resident #28 had arthritis with interventions that included to encourage adequate nutrition. Record review of Resident #28's Physician Orders revealed the following order dated 03/28/2024: Citracal Maximum Oral Tablet 315-6.25 mg-mcg (Calcium Citrate-Vitamin D) Give 2 tablet by mouth two times a day for supplement. Further review of orders revealed the following order dated 03/25/2022 May crush and cocktail medications/open capsules if appropriate for medication administration in food or liquids unless contraindicated. Record review of Resident #28's electronic September 2024 MAR revealed Citracal Maximum Oral Tablet 315-6.25 mg-mcg (Calcium Citrate-Vitamin D) Give 2 tablet by mouth two times a day for supplement. Start Date- 03/29/2024. During an observation on 09/10/2024 at 10:08 a.m., MA administered Calcium 630mg - Vitamin D 12.5mcg 2 tablets crushed and mixed with water to Resident #28. During an interview on 09/12/2024 at 9:52 a.m., MA stated she did not give the correct dose of Calcium Vitamin D. She stated she should have only given 1 tablet instead of 2 tablets to Resident #28. She stated she gave the wrong dose because the directions in order were confusing and had half the dose of Citracal than what was available . Resident #198 675768 Page 11 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #198's electronic face sheet dated 09/12/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, pain, type 2 diabetes mellitus with diabetic chronic kidney disease (kidney disease resulting from type 2 diabetes), and malignant neoplasm of the prostate (prostate cancer). Record review of Resident #198's admission MDS assessment dated [DATE] revealed: BIMS score of 07 which indicated severe cognitive impairment. Record review of Resident #198's physician orders revealed the following order dated 09/03/2024: amlodipine besylate oral tablet 10mg. Give 1 tablet by mouth one time a day for HTN related to hypertensive heart and chronic kidney disease without heart failure. Further review of physician orders revealed the following order dated 09/03/2024: olmesartan medoxomil oral tablet 40mg. Give 1 tablet by mouth one time a day for hypertension related to hypertensive heart and chronic kidney disease without heart failure. No evidence of hold parameters observed on either of these orders. Record review of Resident #198's electronic September 2024 MAR on 09/12/2024 revealed amlodipine besylate 10mg had been held by MA on 09/10/2024 with code 5 meaning hold see progress notes. Further review of September 2024 MAR on 09/12/2024 revealed olmesartan medoxomil 40mg had been held by MA on 09/03/2024 with code 9 meaning other see progress notes, on 09/09/3034 with code 5 meaning hold see progress notes, and on 09/10/2024 with code 5 meaning hold see progress notes. Record review of Resident #198's progress notes reviewed on 09/10/2024 at 4:22 p.m. revealed no notes entered about holding amlodipine besylate and olmesartan medoxomil on 09/03/2024, 09/09/2024, or 09/10/2024. During an observation and interview on 09/10/2024 at 10:44 a.m., MA obtained Resident #198's blood pressure and it revealed a reading of 132/56. The MA went to LVN D and reported the blood pressure reading. LVN D instructed MA to not give amlodipine besylate and olmesartan medoxomil. MA gave Resident #198's medications without amlodipine besylate and olmesartan medoxomil. During an interview on 09/10/2024 at 3:27 p.m., LVN D stated she had been instructed by the NP in the past to not give blood pressure medication if the blood pressure was less than 110/60. She stated the current medication order did not have any parameters to hold medication. During a telephone interview on 09/10/2024 at 4:11 p.m., the MD stated Resident #198 was a new resident into the nursing facility. He stated he expected for his physician orders to be followed. The MD stated physician orders for blood pressure medications should have hold parameters for when the blood pressure was below 130 and the resident was of the age of Resident #198. He stated he should have been notified if his orders needed clarification. He stated no negative impact occurred from medication being held. He stated he would monitor resident's vital signs when he performed his visits by reviewing medical records and make order adjustments then as part of his process for monitoring orders. He stated he had not performed a visit for Resident #198 because he was a new resident in the facility and instructed staff to continue medication orders as written from the hospital discharge until he was able to see the resident. During an interview on 09/11/2024 at 4:23 p.m., the DON stated there were no hold parameters for Resident #198's blood pressure medications. She stated she expected for nurses to hold medications per the nurse's judgement. She stated the facility does not call the doctor often. She expected for the doctor to be notified if the staff held medication more than 2 to 3 times per the nurse's 675768 Page 12 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some judgement. The DON stated she did not know the BON's expectation of nurses holding medications based on nurse's judgement because the BON changed their rules all the time. She stated MA's do not write progress notes and felt the code was selected by the MA because of program restrictions. She did not answer the question on who monitors that physician orders were written appropriately, but stated the order was written appropriately. She stated no negative effect occurred to resident by medications being held and stated the medications would have lowered blood pressure even more. During a follow up interview on 09/12/2024 at 9:36 a.m., the DON continued to state that the facility acted appropriately by holding the blood pressure medication without notifying the MD and no parameters specified in the order. She stated she did expect for correct doses of Calcium and Vitamin D to be administered to the resident. She stated giving the incorrect dose had no negative effect on Resident #28. She stated that pharmacy monitored the MA administering the medications quarterly and they had not found that medications were being administered incorrectly. She did not know why the incorrect dose had been administered. Record review of the facility's policy titled Medication Administration Policy with no date revealed: 1. Must use five rights: the right patient, the right drug, the right dose, the right route, and the right time to reduce risk of medication errors. 2. Must have a basic understanding of any drug that he/she is administering i.e. what the drug is intended to treat, adverse effects and contradictions, expected outcomes and usual route. 3. Must obtain vitals such as blood pressure, heart rate, blood glucose, respirations, oxygen saturation, and pain may be indicated for administration of certain medications. 4. If vital signs are not within parameter, the nurse must hold medication according to physician orders. 5. Nurses may hold doses of medications per nursing judgement if the patient is at risk of suffering from medication administration. Must notify MD of assessment findings promptly. 6. Must document in MAR. According to the Texas Board of Nursing website, https://www.bon.texas.gov/pdfs/publication_pdfs/Scope%20of%20Practice%20Decision-Making%20Model%20-%20DMM.p accessed on 09/12/2024 revealed Scope of Practice Decision-Making Model dated April 2019: 2. Is the activity or intervention authorized by a valid order If there is any question about the accuracy or appropriateness of an order, clarification must be sought [Board Rule 217.11(1)(N)] According to the Texas Board of Nursing website, https://www.bon.texas.gov/rr_current/217-11.asp.html, accessed on 09/12/2024 revealed Board Rule 217.11(1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; 675768 Page 13 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the menu was followed for 3 of 6 (Resident #2, Resident #25, and Resident #33) residents who received a pureed meal reviewed during the lunch meals served reviewed for food and nutrition services. The facility failed to ensure residents, receiving a puree texture diet, were provided the food according to the menu, included a dinner roll on 09/10/2024 and a dinner roll and ice cream on 09/11/2024. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. The findings included: Resident #2 Record review of Resident # 2's Quarterly MDS dated [DATE] revealed an [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Non-Alzheimer's Dementia; Section K- Swallowing/Nutritional Status Resident #2 had a mechanically altered diet. Record review of Resident #2's Care Plan dated 08/07/2024 revealed: Focus-Nutrition: The resident had recent weight loss during hospitalization. Goal- The resident will maintain adequate nutritional status. Interventions- Provide and serve diet as ordered. Record Review of Resident #2's orders dated 06/30/2024 revealed High calorie diet, Pureed texture, regular consistency. Resident #25 Record review of Resident #25's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 10 (moderate cognitive impairment); Section I-Active Diagnosis with following diagnosis of non-Alzheimer dementia; Section K- Swallowing/Nutritional Status Resident #25 had a mechanically altered diet. Record review of Resident #25's Care Plan date 06/19/2024 revealed: Focus-Nutritional Status: the resident had a nutritional problem poor intake. Goal-The resident will maintain adequate nutritional status through review date. Record Review of #25's orders dated 04/03/2024 revealed High calorie diet, Pureed texture, regular consistency. Resident #33 Record review of Resident # 33's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); 675768 Page 14 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Section I-Active Diagnosis with following diagnosis of Non-Alzheimer's Dementia; Section KSwallowing/Nutritional Status Resident #2 had a mechanically altered diet. Record review of Resident #33's Care Plan dated 08/27/2024 revealed: Focus-Nutrition: The resident had recent weight loss during hospitalization. Goal- The resident will maintain adequate nutritional status. Interventions- Provide and serve diet as ordered. Record Review of #33's orders dated 08/23/2024 revealed High calorie diet, Pureed texture, regular consistency. Record review of facility menu week 3 dated 2024 revealed: On Tuesday September 10th, 2024, Lunch included a dinner roll. On Wednesday September 11th, 2024, Lunch included a dinner roll and Ice Cream. During observation on 09/10/2024 at 11:30 AM, the bread was not provided on the pureed diet trays . During an observation and interview on 09/11/2024 at 11:34 AM, the bread was not provided on the pureed diet trays. CNA G stated she felt all residents should have been provided with what was offered on the menu. CNA G asked Resident #33 if she would like to have bread, she stated yes she would. During an interview on 09/12/2024 at 11:57 AM, the ADMN stated the pureed diet came directly from the main menu and did not know if there was a policy for that exact scenario. He stated if there were missing items on the pureed trays, there could be decreased nutritional value for the resident if not replaced appropriately. The ADMN stated the DM monitored the resident diets as well as the Dietician. He stated the residents should have been getting their bread, so they can get their nutritional value of the carbs, and it was an oversight of the DM. During an interview 09/12/2024 at 5:26 PM, the Dietician stated that all residents should have been served everything listed on the menu as that was how they received their balanced diet and nutritional value. She stated the residents that presented with lower cognitive abilities should still have been served what was on the menu. The Dietician stated the CNA's and nurses on the floor should have been monitoring that residents get everything listed on the menu as well as the DM. She stated that miscommunication on the Interdisciplinary Team led to the failure and her expectations were that all residents get everything listed on the menu. Record review of facility policy Therapeutic diets undated, revealed: Policy: It is the policy to serve therapeutic diets according to doctor's orders and need of the resident. Definition: A therapeutic diet is a meal plan that controls the intake of certain foods or nutrients. It is part of the treatment of a medical condition and are normally prescribed by a physician and planned by a dietician. A therapeutic diet is usually a modification of a regular diet. It is modified or tailored to fit the nutrition need of a particular person. Therapeutic diets are modified for nutrients texture, and/or food allergies or food intolerances. Reasons for therapeutic diets; To maintain nutritional status next line to restore nutritional status. 675768 Page 15 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0803 To correct nutritional status. Level of Harm - Minimal harm or potential for actual harm To provide extra calories for weight gain. To balance amounts of carbohydrates, fat and protein for control of diabetes. Residents Affected - Some To provide a greater amount of a nutrient . To provide texture modifications due to problems with chewing and slash or swallowing .Increased fiber should come from a variety of sources including fruits, resumes, vegetables whole breads, and cereals. 675768 Page 16 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. Residents Affected - Some The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. The facility failed to ensure that persons serving food handled food properly. These failures could place residents at risk for food borne illnesses and cross-contamination. The findings included: During an observation on 09/10/2024 at 09:00 AM, the dry storage pantry had: 1. 8 oz. beneprotein powder, no received date 6 total. 2. 4 oz. individual orange juice had no received date. 3. 2 large (size unknown) bottles of ReaLemon juice. 4. 3-7.25 cans of chicken Noodle soup, no received date. During an observation on 09/10/2024 at 9:24 AM, freezer #2 had: 6-1 lb. bags of frozen mixed vegetables with no received date. During observation on 09/10/2024 at 9:27 AM the refrigerator had: 1. 7 gallons of milk had no received date. 2. 2 opened bags labeled red apples had no opened date and no received date. 3. 675768 Page 17 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0812 3 large opened clear bags of what appeared to be jalapenos were not labeled and had no received date. Level of Harm - Minimal harm or potential for actual harm 4. 1 clear gallon bag, of what appeared to be lemons, had no received date. Residents Affected - Some 5. 1 large clear bag of what appeared to be broccoli, had not been labeled and no received date. 6. 3 unbagged bunches of celery was in the bottom drawer of the refrigerator was unlabeled and undated. 7. 12 unbagged, bell peppers, were placed in the bottom drawer of the refrigerator and was unlabeled and undated. 8. 1 large clear bag of cucumbers, not labeled with no received date. 9. 10 heads of lettuce with no received date. 10. One large clear unlabeled and undated box of tomatoes. During an observation on 09/10/2024 at 9:37 AM, there were 2 opened bags of bread on the kitchen shelf, with no opened date or received date. During an interview on 09/10/2024 at 10:00 AM, the DM stated all products were to be dated when received to the facility, as well as labeled if taken out of the product's original boxes. He stated he did not feel it was a big deal as they use the products up fast with no dates needed. The DM stated it was his job to monitor his staff and felt they were complying. He stated there was no failure on his part . During an observation and interview on 09/12/2024 at 9:55 AM, the follow up visit to the facility kitchen revealed there were still vegetables undated in the refrigerator. The DM stated they still did not have dates because they were not in the packages and could not apply dates to the raw vegetables that were in the clear plastic bin. During an interview on 09/12/2024 at 11:52 AM, the ADMN stated all products in the facility kitchen should have had received dates and if opened and out of the original containers should have been 675768 Page 18 of 22 675768 09/12/2024 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 labeled of what the product was. The ADMN stated it was the DM who monitored the process. He stated he could not say what led to the failure nor what his expectations were, as he was unfamiliar with the kitchen policies at this time . During an interview on 09/12/2024 at 5:26 PM, the Dietician stated her expectations were for all products to be labeled and dated as the policy stated . During an observation on 09/10/2024 at 9:00 AM, DA E had not performed hand hygiene and had not applied gloves prior to touching and preparing pineapple for the resident lunch service. During an interview on 09/12/24 9:45 AM, the DM stated he could not provide staff in-services for handwashing. He stated he felt the Hand Hygiene instructions posted on the walls in front of the handwashing sink provided enough information for his staff. The DM stated he monitored his staff but could not state how often or when he monitored as life was too busy. He stated if staff did not wash and sanitize their hands, that it would cause contamination with infecting the residents, which would have made them sick. He stated if they did not wash their hands it was a mistake. During an interview on 09/12/2024 at 11:48 AM, the ADMN stated it was in the policy that all staff were to wash their hands before food being prepped. He stated if staff left the kitchen, they should have washed their hands again. The ADMN stated if staff touched food without being gloved, they should have washed their hands as well, and then gloved. He stated he knew they had plenty of gloves in the kitchen. The ADMN stated in not doing so it could have led to cross contamination with the residents being sick. He stated the DM should have monitored infection control for his kitchen staff, while himself as the ADMN, monitored the DM. He stated that staff had been in-serviced and the documentation was in his office. The ADMN stated his expectations were for the staff to comply with washing their hands. He stated the failure occurred with not washing their hands as well as not and seeking more training. During an interview 09/12/2024 at 5:26 PM the Dietician stated the DM should have monitored his staff better for hand hygiene. The Dietician stated the improper training led to the failure with her expectations, for all staff to follow all policies and procedures with hand hygiene. She stated the negative impact could have been cross contamination and passed to the residents. Record Review of facility policy Food Storage from the Policy and Procedure Manual 82, dated 2008, revealed: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared by methods designed to prevent contamination. Procedure: .7. Hands must be washed after unloading supplies and prior to handling food items. 8 . c. Food should be dated as it is placed on the shelves .15. Refrigeration: . .e. All foods should be covered, labeled and dated .16. Frozen foods: .c. Foods should be covered, labeled, and dated. Review of Texas food Establishment Rules FDA Food Code 2022: Full Document accessed 09/19/2024 revealed Green et al (JFP, March 2007) found that handwashing was more likely to occur in restaurants whose food workers received food safety training, had more than one handwashing sink, and had a handwashing sink in the observed worker's sight. This suggests that improving food worker hand hygiene 675768 Page 19 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0812 requires more than food safety education. Level of Harm - Minimal harm or potential for actual harm Noroviruses are environmentally stable, able to survive both freezing and heating (although not thorough cooking), are resistant to many common chemical disinfectants, and can persist on surfaces for up to 2 weeks. Proper hand hygiene and exclusion of food employees exhibiting symptoms of norovirus disease (i.e., diarrhea or vomiting) are critical for norovirus control. Residents Affected - Some Record review of the United States Food and Drug Administration https://www.fda.gov/food/retail-food-industryregulatory-assistance-training/program-information-manual-retail-food-protectio accessed on 09/19/2024, revealed: Fresh-cut tomatoes and other produce have already been washed before processing and should be considered ready-to-eat with no further need for washing unless the label says otherwise. 675768 Page 20 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (CNA B and LVN D) of 4 staff observed for infection control practices. Residents Affected - Some 1. The facility failed to ensure CNA B removed gloves and performed hand hygiene at the appropriate time while providing resident incontinent care. 2. The facility failed to ensure LVN D sanitized hands at appropriate times when changing gloves during wound care. 3. The facility failed to ensure LVN D sanitized rubber tip of insulin flex pen prior to applying needle to insulin flex pen during administration of insulin to resident. These failures place residents at risk for unnecessary infections while in facility. Finding included: During an observation on 09/10/2024 at 9:43 a.m., CNA B performed incontinent care. CNA B sanitized her hands and put on gloves prior to setting up supplies needed for incontinent care. She removed shirt from closet and assisted the resident to change from sweater into a shirt. She placed the sweater on the dresser. CNA B then asked the resident to stand with the walker while she lowered the resident's pants and removed the urine soiled brief. She wiped the resident front to back with a new wipe every time and disposed of the wipes into the trash. She placed a dry brief onto the resident and assisted with him pulling up the resident's pants. CNA B assisted the resident to sit back into the wheelchair. She then placed the sweater onto a hanger and hung it in the closet. She gathered up all the trash and left the resident's room with gloved hands and trash. She walked down the hall to the shower room and disposed of the trash. CNA B did not remove her gloves or perform hand hygiene until she reached the shower room with the soiled trash and disposed into the trash bin . During an observation on 09/10/2024 at 11:18 a.m., LVN D administered insulin using multi dose flex pen. LVN D performed hand hygiene, removed the lid from the used flex pen, and then placed a new needle onto the flex pen. She did not sanitize the rubber tip of the flex pen prior to applying the needle. During an interview on 09/10/2024 at 3:27 p.m., LVN D stated she had never been told to sanitize the flex pen prior to applying needle and stated the facility policy did not state to sanitize the flex pen prior to applying the needle. During an observation and interview on 09/11/2024 at 9:49 a.m., LVN D performed wound care. LVN D sanitized her hands and gathered her supplies for wound care onto a tray outside of the resident's 675768 Page 21 of 22 675768 09/12/2024 Mountain Villa Nursing Center 2729 Porter Ave El Paso, TX 79930

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room. She then sanitized bedside table in the resident's room with sanitizing wipe. She sat tray with wound care supplies onto bedside table and washed hands prior to applying gloves. She cleansed wound to the left ankle with saline and gauze then removed her gloves. She placed new gloves without performing hand hygiene then applied silver cream to wound bed with wooden applicator, covered wound with gauze, and secured gauze to skin with tape. She removed gloves and disposed into trash and applied new gloves without performing hand hygiene. She cleansed wound to the right ankle with saline and gauze then removed her gloves. She placed new gloves without performing hand hygiene, then applied silver cream to the wound bed with a wooden applicator, covered the wound with gauze, and secured gauze to skin with tape. She removed her gloves and disposed into trash, then washed her hands with soap and water. She carried trash out of the resident's room and placed it into the trash bin on the treatment cart and sanitized her hands again. LVN D stated she should have performed hand hygiene in between glove changes. She stated that she had been nervous due to being watched and forgot to perform hand hygiene . During an interview on 09/11/2024 at 4:23 p.m., the DON stated she expected the nurse to sanitize the insulin flex pen rubber tip prior to placing the needle onto the insulin flex pen. She stated the pharmacy would watch medication passes about once a quarter and she expected for nurses to know how to sanitize the insulin flex pen because they had a nurse's license. She stated she could not supervise nurses all the time. The DON stated she did not know why LVN D failed to sanitize the insulin flex pen and not sanitizing could cause skin infection to the resident. The DON stated she expected for nurses to follow procedure during wound care. She stated LVN D was probably nervous from being watched and forgot to follow procedure. She stated no infection risk due to gloves were a barrier and wounds had not been infected already. The DON stated she expected her staff to change gloves and perform hand hygiene after performing incontinent care and before touching clean areas in residents room including clothing. She stated she monitored staff for hand hygiene and had just had skills check off for hand hygiene either July or August of 2024. She stated she felt staff being rushed and nervous led to the failure. She stated not performing hand hygiene appropriately could cause infection. Review of the facility's policy titled Use of Hand Antiseptic dated 2008 revealed: Hand antiseptics may be used between hand washing as long as hands are not soiled. Hand antiseptics are not to take the place of hand washing. Review of facility's policy titled Policy: Flex Pen Insulin Administration with no date revealed: Pull the pen cap straight off. Wipe the rubber seal with alcohol swab. Check the liquid in the pen. Do not use if cloudy, colored, or has particles or clamps. Select a new needle. Pull off the paper tab from the outer needle shield. Push the capped needle straight on the pen and twist the needle on until it is tight. Review of facility's policy titled Incontinent Care with no date revealed: Disposable diapers are used for incontinent residents. Check every two hours. Change as necessary. Use wipes or washcloth and make sure that the resident is properly cleaned. Discard disposable diaper properly. Review of facility's policy titled Policy: Infection Control Program with no date revealed: C. Handwashing: Single most effective way to control spread of infection. 1. Wash hands in between patient care. 2. Wash hands after using bathroom. 3. Wash hands before and after feeding residents. 4. Wash hands after handling soiled material. 5. Wash hands after using gloves. D. Gloves: 1. Change gloves in between patient care. 2. Wash hands after discarding gloves. 3. Wear gloves when handling soiled materials. 4. Discard in designated containers. 675768 Page 22 of 22