Health inspection·January 10, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 32 residents (Resident #50) whose assessments were reviewed: Residents Affected - Few Resident #50's use of tobacco was not identified on the resident's annual MDS assessment with an ARD of 02/23/2024. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #50's face sheet, dated 01/10/2025, revealed an admission date of 04/06/2018 with diagnoses that included hyperlipidemia (a condition where the blood has too many fats such as cholesterol or triglycerides), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #50's comprehensive care plan dated 11/29/2024 revealed a focus are stating, I am a smoker (vapor cigarette) and also dip tobacco. The goal was for the resident to be allowed to smoke safely and independently and interventions included several safe smoking procedures. Record review of Resident #50's Annual MDS dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Section J - Health Conditions, J1300. Current Tobacco Use, revealed Code 0 was checked (0 indicated No). During an interview on 01/10/2025 at 2:15 PM, RN H stated Resident #50's annual MDS with an ARD of 02/23/2024 was coded incorrectly in Section J, as it indicated the resident did not use tobacco when Resident #50 used dip tobacco regularly. She was responsible for completing the MDS and the error was an oversight, since the resident had once used a vape cigarette and quit that method of tobacco use two years prior. She had been in the position for approximately 18 months and had been trained by her predecessor and the corporate MDS coordinator. It was important to complete the assessment accurately to ensure it captured all the resident's health conditions for the provision of proper care. During an interview on 01/10/2025 at 2:30 PM, the DON she stated she had seen Resident #50 use smokeless tobacco in the smoking area of the facility, and she was unaware his annual assessment did not reflect his use of tobacco. Page 1 of 10 675863 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/10/2025 at 2:45 PM, RN I stated the facility used the RAI manual as their policy for MDS and Care plan updating. Staff had the manual available digitally. Record review of the CMS RAI Version 3.0 Manual J1300 Current Tobacco Use revealed, Coding Instructions: Code 0, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. 675863 Page 2 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 32 residents (Resident #50) reviewed for care plans, in that: The facility failed to update Resident #50's comprehensive care plan to remove the focus area indicating the resident smoked tobacco. This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #50's face sheet, dated 01/10/2025, revealed an admission date of 04/06/2018 with diagnoses that included hyperlipidemia (a condition where the blood has too many fats such as cholesterol or triglycerides), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) and post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #50's quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #50's comprehensive care plan dated 11/29/2024, revealed a focus are stating, I am a smoker (vapor cigarette) and also dip tobacco. The goal was for the resident to be allowed to smoke safely and independently and interventions included several safe smoking procedures. During an interview on 01/10/2024 at 1:55, the DON stated Resident #50 had quit smoking a while ago and the focus area of smoking in the comprehensive care plan should have been updated to indicate he used dip tobacco but did not smoke or use a vape cigarette. She had seen the resident use smokeless tobacco in the smoking area of the facility. The MDS LVN was responsible for updating care plans. During an interview on 01/10/2025 at 2:07, RN H stated comprehensive care plans were updated every three months or as needed. She had received training from the facility's previous MDS coordinator and the corporate MDS coordinator. She should have removed the smoking part of the focus area of Resident #50's care plan; she had only seen the section indicating he used dip tobacco and missed it. It was important to update the comprehensive care plan to ensure it reflected all the resident's health conditions for the provision of proper care. During an interview on 01/10/2025 at 2:45 PM, RN I stated the facility used the RAI manual as their policy for MDS and Care plan updating. Staff had the manual available digitally. 675863 Page 3 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #13) reviewed for incontinent care. The facility failed to ensure CNA A and CNA B thoroughly cleaned Resident #13 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #13's face sheet, dated 01/09/2025, revealed an admission date of 01/10/2022, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypothyroidism (under active thyroid), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function) and, Guillain-Barre syndrome (condition in which the body's immune system attacks the nerves. It can cause weakness, numbness or paralysis). Record review of Resident #13's Quarterly MDS assessment, dated 12/19/2024, revealed Resident #13 had a BIMS score of 12, which indicated mild to moderate cognitive impairment. Further review revealed Resident #13 required extensive assistance to total care with ADLs and was indicated to frequently be incontinent of bladder and bowel. Record review of Resident #13's care plan, dated 12/12/2024, revealed a problem of At risk for infection or recurrent/chronic infection related to compromised medical condition, with a goal of I will not experience any complications or adverse reactions throughout the course of treatment and the illness/infection will resolve. Observation on 01/09/25 at 10:44 a.m. revealed, while providing incontinent care for Resident #13, CNA A did not clean between the labia of the resident and did not clean the urinary meatus (urinary opening). Further observation revealed, while being turned on her side, the resident urinated and CNA A and CNA B did not clean her genital area a second time before placing a clean brief on the resident. During an interview on 01/09/2025 at 10:55 a.m. CNA A and CNA B stated she did not clean between the resident's labia because she did not want to be too invasive. CNA B stated she should have cleaned the urinary opening. The two CNAs confirmed not cleaning the resident a second time after she urinated. They had no explanation. CNA A stated she had received training for infection control and incontinent care within the last year from the RN in charge of infection control. During an interview with the DON on 01/09/2025 at 3:45 p.m., the DON stated the urinary meatus area had to be cleaned. The DON stated the staff should have cleaned the resident a second time if she had urinated after being cleaned. The DON stated the infection preventionist was responsible for training the staff in infection control and incontinent care and that performance skills checks were completed annually and as needed by the ADON, the Infection Preventionist and herself. 675863 Page 4 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0690 Record review of facility policy, titled Competency Assessment Perineal Care , February 2018, revealed [ .] Separate labia and wash are downward from front to back. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675863 Page 5 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 1 of 6 medication carts (Hall 500 Medication Aide carts) reviewed for medication labeling and storage. The facility failed to ensure a bottle of Ciprofloxacin 0.3% ophthalmological solution for Resident #135, which had been previously opened was labeled with an open date. This failure could place residents at risk of receiving expired medications. Findings included: Record review of Resident #135's face sheet dated 01/09/2025 revealed he was a [AGE] year old man with an admission date of 08/22/2024 and diagnosis which included: Asthma (condition where airways swell, causing extra mucus, making it difficult to breathe), abnormalities of gait and mobility, and chronic allergic conjunctivitis (infection of the outer membrane of the eyeball and inner eyelid). Record review of Resident #135's order summary dated 01/09/2025 revealed an order for Ciprofloxacin HCL Ophthalmic Solution 0.3% instill 2 drop in both eyes two times a day for conjunctivitis for 7 days supervised self-administration. Observation on 01/09/2025 at 8:13 a.m. of the Hall 500 Medication Aide cart revealed one opened bottle of Ciprofloxacin 0.3% Ophthalmological solution labeled with Resident #135's name, but without an open date written on the bottle. During an interview with MA C on 01/09/2025 at 08:32 a.m., MA C confirmed there was no open date written on the bottle of Ciprofloxacin eye drops for Resident #135, and that it had been previously opened. MA C noted the fill date on the pharmacy label showed the medication was filled on 01/07/2025, and that eye medications were good for 30 days after opening, so the eye drops could not be expired. However, MA C further stated that each medication should be marked with an open date, so that Nurse's will know when the medication does expire. MA C stated that it was the responsibility of the Nurse who opened the medication to label the medication with the open date. Interview on 01/10/2025 at 11:40 p.m. with the DON revealed that the expectation was for all Nurse's and Medication Aides to label each medication with its open date, since medications such as eye drops, were good for only 30 days past the open date, and without an open date, nurse's could not determine the expiration date of the medication. The DON noted that some eye medications could start to lose effectiveness 30 days after opening. Record review of the facility policy titled Pharmacy Services revised January 2023 revealed Medications and biologicals are labeled in accordance with currently accepted professional standards and with local and state drug-labeling regulations and The critical elements of the drug label include: .expiration dates. 675863 Page 6 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #23, #90 and #135), reviewed for infection control. Residents Affected - Some 1. The facility failed to implement contact precautions for Resident #23 after it was ordered by the physician. 2. The facility failed to ensure proper infection control practices during wound care for Resident #23, when LVN D did not change gloves or sanitize their hands after cleansing the resident's wound, and before picking up and placing a new dressing on the resident's wound. 3. The facility failed to use proper infection control practices during medication administration for Resident #90, when MA G grabbed the cup of water with a pinching movement between her thumb and forefinger, with her forefinger inside the cup, thumb on outside of cup and her hand resting on the top lip of the cup to take it into the resident's room. 4. The facility failed to ensure proper infection control practices during supervised self-medication administration of eyedrops for Resident #135, MA C failed instruct the resident to sanitize their hands prior to self-applying the eyedrops, and failed to observe the resident as they self-applied eyedrops and then proceeded to wipe excess medication that had leaked down the resident's face with both hands and used their soiled hands to replace the cap on the bottle of eyedrops. These deficient practices could place residents at risk for infection and decline in health. Findings included: 1. Record review of Resident #23's face sheet dated 01/08/2025 revealed she was a [AGE] year-old woman who was admitted on [DATE] with diagnoses which included: Dementia (a general term for loss of memory, language, problem-solving and other thinking ability severe enough to interfere with daily life), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar), and Resistance to Vancomycin related antibiotics. Record review of Resident #23's Quarterly MDS, dated [DATE], revealed a BIMS score of 08, indicating moderate cognitive impairment. Record review of Resident #23's Order Summary, dated 01/08/2025, revealed orders for: - Contact isolation precautions: Isolate in place required in which all care, therapy and other services are provided in room r/t an active infection dated 01/07/2025. - Tx [treatment] to right lateral foot Cleanse with normal saline, pat dry. Apply 10% iodine solution to wound bed. Cover with 4x4 gauze and abd pad, wrap with kerlix, secure with tape or ace wrap. Wrap foot with moisture wicking pad and apply heel protector. Change twice daily and as needed. Observation on 01/08/2025 at 11:32 a.m. revealed Resident #23 was sitting in her wheelchair in the 675863 Page 7 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0880 Level of Harm - Minimal harm or potential for actual harm day room watching TV, with 2 other residents sitting on both sides of her. Further observation of the outside of Resident #23's room revealed an Enhanced Barrier Precautions sign on the wall to the right of the door, and a yellow Contact Isolation Sign posted on the front of her door. The door was in the open position and the Contact Isolation sign was not immediately visible when looking straight at the room. There was PPE supply available outside the door. Residents Affected - Some During an Interview with LVN E on 01/08/2025 at 11:41 a.m., LVN E stated she was not aware of the order for Contact Isolation for Resident #23, and immediately checked to verify. LVN E stated Resident #23 had a wound on her foot and therefore had been on Enhanced Barrier Precautions but was not aware of the change in orders to Contact Isolation. LVN E stated that the order for contact isolation was not provided to her during shift change this morning and was not included in the 24-hour report. LVN E stated Resident #23 should not be in the day room in close contact with other residents while under contact isolation, and immediately asked one of the CNA's to assist Resident #23 back into her room. LVN E stated that not implementing and following contact isolation procedures when ordered could result in spread of infection. During an interview with LVN F on 01/08/2025 at 11:46 a.m., LVN F stated he was the Infection Control Nurse and confirmed the order for Contact Isolation for Resident #23 was given the day before (01/07/2025) due to an MDRO (multi-drug resistant organism) found in Resident #23's urine culture. LVN F stated he verbally told the Nurse on duty yesterday about the order for Contact Isolation for Resident #23 and placed the contact isolation sign on her door. LVN F stated he did not know why that information was not passed to the next shift and stated it should have been put it on the 24-hour report as well. LVN F stated that not implementing Contact Isolation procedures when ordered could result in spread of infection and noted that the Enhanced Barrier Precautions sign should have been removed when Resident #23 was placed on contact isolation, as having both the EBP sign and Contact Isolation sign up could be confusing for staff. Observation of wound care for Resident #23 on 01/09/2025 starting at 11:54 a.m. revealed LVN D cleansed the wound on the right lateral foot with saline, patted dry with gauze, and then without changing gloves and sanitizing hands, picked up and placed a new clean gauze padding covered with Betadine on top of the wound, and completed wrapping as per physician order. During an interview with LVN D on 01/09/2025 at 12:10 p.m., LVN D stated yea, I guess I should have when asked if she should have changed her gloves and sanitized her hands after cleansing the wound, and before picking up and applying clean dressing to wound. LVN D stated gloves should be changed whenever going from dirty to clean. LVN D stated that by not changing her gloves and sanitizing in between cleaning the wound and placing a clean dressing, it could spread infection. Record review of the Licensed Nurse Competencies Checklist dated 02/19/2024 for LVN D revealed she was checked off as being competent in demonstrates understanding and competency of Dressing Change Clean & Sterile. 2. Record review of Resident #90's face sheet dated 01/10/2025 revealed he was an [AGE] year-old man, admitted [DATE] with diagnoses which included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions); Parkinsonism (movement disorder), and Diabetes Mellitus Type 2 (a long-term condition in which the body has trouble controlling blood sugar). Record review of Resident #90's MDS Quarterly dated 11/06/2024 revealed a BIMS score of 03, indicating severe cognitive impairment. 675863 Page 8 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 01/09/2025 at 07:37 a.m. of Resident #90's medication pass, revealed MA G, while preparing medications for Resident #90, filled a plastic cup with water. MA G then grabbed the cup of water with a pinching movement between her thumb and forefinger, with her forefinger inside the cup, thumb on outside of cup and her hand resting on the top lip of the cup to take it into the resident's room. During an interview with MA G on 01/09/2025 at 09:29 a.m., MA G stated she should not have touched the inside or top lip of the water cup with her hands/finger for Resident #90, as this could result in cross-contamination. MA G stated she knew better, and has received training in infection control, but just forgot while trying to carry all the medications and supplies into Resident #90's room at the same time. During an interview with the DON on 01/10/2025 at 01:56 p.m., the DON stated staff should not touch the inside or lip of resident's drinking cups as this could lead to cross contamination. The DON stated MA G has received training in infection control. Record review of MA G's Competency Checklist dated 01/10/2024 revealed she was checked off as meeting competency in infection control. 3. Record review of Resident #135's face sheet dated 01/09/2025 revealed he was a [AGE] year old man with an admission date of 08/22/2024 and diagnoses which included: Asthma (condition where airways swell, causing extra mucus, making it difficult to breathe), abnormalities of gait and mobility, and chronic allergic conjunctivitis (infection of the outer membrane of the eyeball and inner eyelid). Record review of Resident #135's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #135's Care Plan initiated 08/22/2024 revealed focus areas which included: - At risk for infection or recurrent/chronic infection r/t compromised medical condition: 9/24/24: Conjunctivitis (infection of the outer membrane of the eyeball and inner lid) and 01/07/2025: Conjunctivitis; and - I am at risk for vision loss/impairment: Conjunctivitis - 11/20/2024. Record review of Resident #135's order summary dated 01/09/2025 revealed an order for Ciprofloxacin HCL Ophthalmic Solution 0.3% instill 2 drops in both eyes two times a day for conjunctivitis for 7 days supervised self-administration with a start date of 01/07/2025. Record review of Resident #135's Self-Administration of Medication assessment dated [DATE] revealed Resident #135 was checked as having basic competency to identify his medications, state what the medication was used for and to administer eye drops or eye ointments with Approval by IDT for self-administration of medications. Observation on 01/09/2025 at 08:13 a.m. of Resident #135's medication administration pass by MA C revealed MA C administered all of Resident #135's oral medications to him, however, she provided the container of Ciprofloxacin HCL Ophthalmic Solution 0.3% directly to Resident #135 for him to 675863 Page 9 of 10 675863 01/10/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some self-administer, noting he wanted to administer his own eye drops. Resident #135 was not prompted by MA C to wash or sanitize his hands prior to administration of the eye drops and was observed to administer the drops in his eyes, resulting in excess fluid running down his cheeks from both eyes. Resident #135 was then observed to wipe the excess fluid off his cheeks with both hands. He then grabbed the bottle of Ciprofloxacin with the same hand that had wiped off excess fluid from his eyes and handed it back to MA C, who replaced the bottle of Ciprofloxacin into its box container and then into the medication cart, without cleaning the outside of the bottle, or prompting Resident #135 to wash his hands. Interview on 01/10/2025 at 11:40 p.m. with the DON revealed that the expectation for supervised self-administration of medication was that the Nurse or Medication Aide would observe the self-administration to ensure the correct number of drops and correct technique was used by the resident, including infection control procedures such as hand washing. If correct procedure or infection control procedure was not followed by the resident, she would expect the supervising medication aide to intervene and educate the resident on correct procedure. The DON stated that by not having the resident wash his hands prior to and after administration of eyedrops and after touching the excess fluid from his eyes could result in cross contamination, leading to further incidents of conjunctivitis. The DON further stated the Medication Aide should have sanitized the outside of the Ciprofloxacin bottle after the resident had grabbed it with hands that had wiped fluid from his eyes, to prevent spread of infection. Record review of CDC Guidelines at https://www.cdc.gov/conjunctivitis/prevention/index.html, dated 04/15/2024 for prevention of conjunctivitis revealed recommendations which included: 1) Wash your hands before and after cleaning or applying eye drops or ointment to your infected eye; 2) If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol to clean hands: 3) Avoid touching or rubbing your eyes with your fingers; 4) With clean hands, wash any discharge from around your eyes several times a day using a clean, wet washcloth or fresh cotton ball - throw away cotton balls after use and wash used washcloths with hot water and detergent then wash your hands again. Record review of facility policy titled Infection Prevention and Control revised April 2024 revealed under section titled Important facets of infection prevention include: .implementing appropriate isolation precautions when necessary. Continued review revealed Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surface or patient-care items in the resident's environment. Under section Implementation of Isolation and/or Precautions: Post clear signage .on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves). 675863 Page 10 of 10