Health inspection·April 18, 2024

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 observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four (Resident #12, #18, #44, and one unknown resident) of six residents reviewed for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: The door of the central supply closet, that contained direct care products: mouth wash, razors, shaving cream, toothpaste, denture cleaner, conditioning shampoo, body lotion, and orange stick located on Hall 400 was open and accessible to residents. Resident #12, a confused resident, was in close proximity to the central supply, with no staff within line of sight of the supply closet. The facility failed to properly maintain wheelchairs for Residents #12, #18, and #44. These deficient practices could place residents at risk for ingesting direct care products, fall, and exposure to skin tears that could be detrimental to his or her health, resulting in illness or hospitalization. Findings included: Record review of the Face Sheet for Resident #12 dated 04/16/2024 revealed she was [AGE] year-old female was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's, dementia, and hypertension. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #12 scored 3 of 15 on the BIMS, indicative of severe cognitive impairment. The MDS reflected the resident exhibited inattention and disorganized thinking. The MDS reflected Resident #12 was able to propel her wheelchair. Resident #1 did not have functional limited range of motion of any extremities and wore a wander guard on the right ankle for behaviors of wandering. Record review of the Care Plan for Resident #12 (edited 04/02/2024) revealed the resident could propel her wheelchair short distances without the assist of staff with updates reflected goals and approaches to include wheelchair mobility for locomotion The Care Plan, reflected Resident #12 had a memory/recall deficit, and was disoriented to date/time, and had short-term memory loss. The 'Goal' read, in part, .Resident will not sustain serious injury due to memory/recall deficit. The 'Approach' Page 1 of 9 675811 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some read, in part, .Ensure resident's areas are free of hazards. Review of the Resident #12's plan of care edited 04/02/24 Observation on 04/16/2024 at 12:50 p.m., revealed the door of the central supply at the entrance to Hall 400 was open. An unknown resident was going into the central supply room . Resident #12 was observed in the hallway in her wheelchair following the other resident into the central supply room. She was independently propelling her wheelchair. There was no staff within visibility of the central supply or Resident #12. Observation on 04/16/2024 at 1:00 p.m., revealed LVN A walked by and stated to the two residents what are you two doing in there? The unknown resident stated she was getting Kleenex; Resident # 12 just looked at LVN A. The LVN told the unknown to resident to come out and helped Resident #12 to get out the supply closet. Resident #12 stated well I did not get anything I will just have to come back another time. LVN A told both resident's they should not be in there, that was for staff only. Observation on 04/16/2024 at 1:10 p.m., revealed the central supply closet did not have a lock on it. The closet contained: mouthwash, toothpaste, razors, shaving cream, body lotion, conditioning shampoo, denture cleaner, orange sticks, and various tubing for foley catheters and oxygen tubing. Interview on 04/16/2024 at 1:15 p.m. LVN A stated she had never seen any resident go into the central supply room, but she guess there was always a first. LVN A stated she thought they needed a lock on it now. LVN A stated the residents could have ingested something that was not good for them. Observation and interview on 04/16/2024 at 3:00 p.m., the DON revealed she said the door of the central supply closet has never had a lock on it that she could recall, but she was going to tell the Administrator that it should have been locked. She said the resident could have ingested the direct care products and had side effects. Interview on 04/16/24 at 3:30 p.m. with the Administrator revealed he was unaware the central supply closet did not have a lock on it, and he would see that one was placed immediately. The Administrator stated that was not safe the residents could get items and swallow them making them sick. Observation on 04/16/24 at 12:30 p.m., revealed Resident #12's wheelchair's bilateral armrests were cracked with jagged edges and foam exposed. Resident #18 Record review of the Face Sheet for Resident #18 dated 04/16/2024 revealed she was [AGE] year-old female, was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unsteady gait, generalized weakness, dementia, and hypertension. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #18 scored 7 of 15 on the BIMS, indicative of severe cognitive impairment. The MDS reflected the resident exhibited inattention and disorganized thinking. The MDS reflected Resident #18 was able to propel her wheelchair. Review of the Resident #18's plan of care edited 03/21/24 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 04/16/24 at 12:33 p.m., revealed Resident #18's wheelchair's right armrest was 675811 Page 2 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0689 cracked with jagged edges and foam exposed. Level of Harm - Minimal harm or potential for actual harm Resident #44 Residents Affected - Some Record review of the Face Sheet for Resident #44 dated 04/16/2024 revealed she was [AGE] year-old female, was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unsteady gait, generalized weakness, dementia, limited range of motion. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #44 scored 7 of 15 on the BIMS, indicative of severe cognitive impairment. The MDS reflected the resident exhibited inattention and disorganized thinking. The MDS reflected Resident #44 required a wheelchair for mobility and the staff was required to propel her wheelchair. Review of the Resident #44's plan of care edited 01/29/24 with updates reflected goals and approaches to include wheelchair mobility for locomotion and total assist of staff. Observation on 04/17/24 at 1:33 p.m., revealed Resident #44's wheelchair's bilateral armrests was cracked with jagged edges and foam exposed. Interview on 04/17/24 at 2:45 p.m. revealed LVN A stated that if a resident had a problem with their wheelchair requiring repair, would tell the DON, or the Administrator. LVN A stated we use to use the computerized maintenance system, but we do not have a maintenance man right now, so there would be no one to see it. LVN A stated if the CNAs see required equipment repair, they are supposed to let us know. LVN A stated she was not aware of any wheelchairs that required repair. Interview on 04/18/24 at 11:00 a.m. with the DON reflected at this present time the facility does not have a maintenance man. The DON stated informed the staff to report to her, if any piece of equipment including wheelchairs required repair, we would find them a new wheelchair to use, since we do not any parts at this time. The DON stated the facility was not using the maintenance computerized system since there would be no one to read the input for repairs. The DON stated he was not aware of any wheelchair that required fixing. Interview on 04/18/24 at 12:15 p.m. with Administrator revealed that the staff was supposed to let someone know and we would get the resident another wheelchair, that is what the DON just communicated to me. Review of the facility policy entitled Receipt and Storage of Supplies and Equipment revised November 2009 reflected, Our facility shall verify shipments .2. Supplies should be stored in their designated storage areas .7. Hazardous/toxic materials must be properly stored/secured . Review of the facility policy entitled Maintenance Services revised December 2009 reflected, Maintenance service shall be provided to all areas of the building, grounds, and equipment The Maintenance Department is responsible for maintenance . equipment in a safe and operable manner at all times . the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the Equipment are maintained in a safe and operable manner 675811 Page 3 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filter and vent were free from dirt and dust. 2. The facility failed to ensure the ice machine chute guard was clean. 3. The facility failed to ensure food items in the refrigerator (1 of 2), freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers and dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure multiple food items stored in a bin/container were clearly identifiable. 5. The facility failed to inspect produce inventory and monitor for spoilage or over ripening and to discard spoiled, moldy, or over ripened food items. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen: Receiving Area (location of the ice machine) on 04/16/23 at 10:44 AM revealed the following: -The ice machine's plastic vent, located on the left side and right side of the machine, the vent slats had dust on them. -The ice machine's ice chute guard had a light pink stain across the length of the chute guard. Observations of the reach-in refrigerator on 04/16/24 at 10:55 AM revealed the following: -On the left side, on the 2nd row from the top, was a small pink plastic basket of 6 chocolate house shakes, dated 04/15/24 to 05/15/24. There were 3 blueberry, 2 strawberry and 4 raspberry Light and Fit yogurts in the baskets as well. There was no label of item description of all that was in the basket, no received by date, and no consume by or discard by date for the yogurts. -On right side of the refrigerator, 1 small square metal pan covered with plastic wrap with 6 cheese sandwiches inside labeled cheese, dated 04/16/24. There was no correct or full label of item description and no consume by or use by date. Observations of the Kitchen on 04/16/24 at 10:57 AM revealed the following: -On a prep. table across from the reach-in refrigerator, there is a sheet pan with 6 peanut butter 675811 Page 4 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0812 Level of Harm - Minimal harm or potential for actual harm and jelly sandwiches in individual plastic sandwich bags. The sticker on the sheet pan was labeled 04/16 (04/16/24). There was no label of item of description, no consume by or end by date. - Hanging pan rack on the wall over the 3-compartment sink, there was a metal strainer with one of the wires broken and sticking out on the bottom right corner. It was in disrepair. Residents Affected - Some Observations of the walk-in refrigerator on 04/16/24 at 11:20 AM, accompanied by the Dietary Manager, revealed the following: -1-2 stack (20 or more slices) of Provolone cheese in plastic vacuum pack. There was no label of item description, no received by date, no open date and no end date. -1 small stack (15 or more slices) of provolone cheese wrapped in plastic wrap, dated 04/16/24. There was no label of item description, no received by date, and no consume by or end date. -1 pack of sliced cheddar cheese, there was no label of item description, no received by date, no consume by or end date. -1 square medium clear container with lid containing broccoli salad/medley, labeled broccoli 4/24 (04/2024). There was no correct label of item description, no correct prepared date and no consume by or end by date. -1-32 oz clear plastic zip top bag of seedless green grapes. There was no received by date, no open date, no consume by or end by date. The bag was also left open to air (not resealed securely). -2-1lb. square clear plastic container with a lid containing whole strawberries, in a bin dated 04/15/24. There was no received by date on each container, no consume by or discard by date. 2-3 of the strawberries in each of the containers had white fuzzy and green mold on it. -1 small metal square pan with approximately 10 boiled eggs, previously opened, dated 04/16/24; there was no consume by or end by date. Observations of the Dry Storage Room on 04/16/24 at 11:51 AM revealed the following: -1 extra-large clear container with lid containing uncooked rice dated 04/20/23. There was no consume by or discard by date. -1-1gal. liquid butter alternative oil dated 04/08/24, there was no open date, no consume by or discard by date. -1-16 oz. bottle of kiwi-lime dessert sauce, previously opened; there was no received by date, no opened date and no consume by or discard by date. Manufacturing use by date 02/23/24. -1-16 oz. bottle of blackberry dessert sauce, there was no received by date and no consume by or discard by date; manufacturing use by date 01/02/24. -1-16 oz. bottle of mango dessert sauce, there was no received by date and no consume by or discard by date; manufacturing use by date 02/23/24. 675811 Page 5 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0812 Observations of the walk-in freezer on 04/16/24 at 11:53 AM revealed the following: Level of Harm - Minimal harm or potential for actual harm -1 large zip top bag with 6 biscuits; there was no label of item description, no open date, no consume by or discard by date. Residents Affected - Some Observations of the walk-in refrigerator on 04/17/24 at 10:00 AM, Accompanied by the Dietary Manager, revealed the following: -1-32 oz clear plastic zip top bag of seedless green grapes. There was no received by date, no open date, no consume by or end by date. The bag was also left open to air (not resealed securely), remained in refrigerator. -4-1lb. square clear plastic container with a lid containing whole strawberries, in a bin dated 04/15/24. There was no received by date on each container, no consume by or discard by date. 3-4 of the strawberries in each of the containers had white fuzzy and green mold on it. The previous (noted 04/16/24 2 containers remained in the walk-in refrigerator. In an interview on 04/16/24 at 10:58 AM with the Dietary Manager, she stated she does the inventory and they (the facility) had just had a truck yesterday (04/15/24) but she did not get to put all the dates on the signs she made (referring to the laminated ingredient tags made attached on bin for certain items). The Dietary Manager said, open items in the refrigerator are kept for 3 days, depending on the item but like cooked food, we keep for 3 days in the refrigerator. She stated that the vendor that they use now, usually when there was an issue on veggies and produce she can take a picture, send it to the food vendor and then trash the item to get credit, for example in the case of the bananas, she just gets them from a local store because they always come from the vendor looking bad. The Dietary Manager stated they check the food before receiving it but sometimes, for example, if she was not here when they deliver then she can come in and find the food sitting in the refrigerator (if its needs to remain cool) or in kitchen (for room temperature/shelf stable items). She also stated the Cooks do the inventory for the freezer and refrigerators and the Dietary Aids do it for the dry storage. The Dietary manager stated the cook was in-charge in her absence. The Dietary Manager stated they keep items like liquid butter alternative, once opened, 30 days, grits once opened 60 days, dry uncooked noodles once opened, not over 3 months and opened dry cereal, not pass 60 days as examples of how long items are kept in dry storage, once opened. In an interview on 04/17/24 at 11:51 AM the Dietary Manager said, the bag (seedless grapes) should have had a received by date and open date and a use by date? The surveyor affirmed her question. The Dietary Manager was asked if she noted any other issues with the bag of grapes (the zip top bag was not sealed). The Dietary Manager stated she noted the strawberries (she threw out 3 of the 4 packs of the strawberries with the surveyor present). She said, if they use anything pass the best by date it is no more than 7 days past the manufacturer's best by date but nothing in the kitchen last long enough to get to that date. Review of the facility's Nutrition Services Food Storage Policy, Policy No.: 03.003, Version 1.0, Date Revised June 1, 2019, reflected Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry Storage rooms: . d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that 675811 Page 6 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the older items are used first. 2. Refrigerators: . d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that ate approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers: . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in Law, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov 675811 Page 7 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for two (Halls 100, 400) of two halls, the facility's only nurse's station, and only dining room, observed for pest control program. Residents Affected - Some The facility had live flies various in areas of the facility including the nurse's station, Halls 100, 400, and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Included: The facility had live flies in areas of the facility including the nurse's station, Halls 100, 400, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation on 04/16/24 at 09:15 a.m. a fly flew around the ceiling light in the conference room, then landing on the table. Observation on 04/16/24 at 9:25 a.m. there was a fly in the central supply room at the end of Hall 400, crawling on the open boxes that had formula stored in them. The fly continued to crawl on the bottle tops of the enteral formal. Observation on 04/16/24 at 11:30 a.m., revealed a fly flew down Hall 100 and landing on the exit door at the end of the hallway. Observation on 4/16/24 at 12:05 p.m., revealed a fly in the main dining room crawling on one the dining room tables. Observation and interview on 04/16/24 at 12:50 p.m. revealed a fly crawling on the top of the table, there were two residents at the table and the one shooed the fly away. One of the unknown female residents at the table stated we have flies in here sometimes it depends on how often the door was open and closed. Observation and interview on 04/16/24 at 1:00 p.m. with a family member, who was assisting with care to her family member revealed there was a fly crawling on the dirty linen in the bag and then flew onto the feeding pump for the resident. The family member stated the flies have gotten worse; had seen several in his room recently. The family member stated she comes almost daily, and she has seen the pest control man here in the last week. The family member stated she had not asked or reported the flies she had seen. Observation on 04/16/24 at 2:30 p.m. revealed a fly crawling on the fire door leading into Hall 400. 675811 Page 8 of 9 675811 04/18/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 04/17/24 at 12:45 p.m., in the main dining room, in the main building revealed a fly crawling on left-over food on the table. In an interview on 04/17/24 at 2:45 p.m. with LVN A revealed that the pest control man was here every week. The LVN stated she would tell him if she saw any flies but have not seen any recently. LVN A stated there had been occasional times she had seen flies at the nurse station, but they would fly away and would not see them anymore. The LVN stated she had not reported that to anyone or written it in the pest control log. Interview on 04/17/24 at 3:00 p.m. with The DON revealed the pest control man showed up here all the time, there was a log at the nurses station the staff could write in, if they observed, pest, but I have not seen any. Interview on 04/18/24 at 12:15 p.m. with the Administrator revealed he had not seen any flies and he was going to have to speak to the pest control man. He stated it was getting to be fly season and he would see what the pest control could do. Review of the pest control visits for the past three months reflected the following: 1) 02/14/24 logbook at the nurse station no pest sightings entered fly service glue traps replaced . (10 flies captured in the kitchen trap) . 2) 02/21/24 logbook a t he nurses station checked no entries . 3) 03/06/24 logbook noting documented on pest control log at the nurses station . Fly lights serviced glue traps replaced . ( 20 flies captured in the hallway trap) and ( 30 flies caught in the kitchen fly trap) . 4) 04/16/24 Nothing documented in the logbook at the nurse's station . power spray on extremities for crawling and flying insects . ( 10 flies captured on the hallway fly traps) . (15 flies caught in the kitchen traps) Record review of the Facility's Pest Sighting Log revealed:11/26/23 was the last time the logbook at the nurse's station had been written in. There were no current pest control logs filled out for 2024. Record review of the facility's policy revised September 2023, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents 675811 Page 9 of 9