Health inspection·May 17, 2023

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 observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #11, Resident #30, and Resident #2) of 13 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a bolster (long padded cushion with sides) on the bed for safety and positioning for Resident #11. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a bed alarm in the bed and the use of a geri-chair for safety and positioning for Resident #30. 3. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a pommel cushion (cushion in a wheelchair) for safety and positioning for Resident #2. These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Resident #11 Review of Resident #11's electronic face sheet accessed 05/16/2023, revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Epilepsy (seizures), anxiety, and profound intellectual disabilities. Review of Resident #11's Quarterly MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score interview not conducted. Section I: Active Diagnosis: Epilepsy. Section P: Restraints and Alarms No restraints or alarms used. Section G: Bed mobility: Total dependence with two-person physical assist. Review of Resident's #11's electronic care plan initiated 04/16/2020, revealed no evidence of a focus, objective, or interventions related to the use of a bolster (long padded cushion with sides) in bed for safety and positioning. Page 1 of 11 675866 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 05/16/2023 at 09:40 AM, revealed Resident #11 lying in bed with a bolster cushion in place on bed underneath resident. Resident was unable to answer questions. Resident #30 Review of Resident #30's electronic face sheet accessed 05/16/2023, revealed resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: Alzheimer's, dementia, and psychotic disorder. Review of Resident #30's admission MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score of 03 indicating severe cognitive impairment. Section I: Active Diagnosis: Alzheimer's and Dementia. Section P: Restraints and Alarms No restraints or alarms used. Section G: Bed mobility: Extensive assistance with two-person physical assist. Review of Resident's #30's electronic care plan initiated 03/30/2023, revealed no evidence of a focus, objective, or interventions related to the use of a bed alarm and the use of a geri-chair for safety and positioning. During an observation on 05/16/2023 at 09:45 AM, revealed Resident #30 lying in bed with a bed alarm in place under blanket on her bed. During an observation on 05/17/2023 at 2:00 PM, revealed Resident #30 sitting in a geri-chair. Resident was unable to answer questions. Resident #2 Review of Resident #2's electronic face sheet accessed 05/16/2023, revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: muscle wasting, reduced mobility, and anxiety. Review of Resident #2's Annual MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score of 09 indicating moderate cognitive impairment. Section I: Active Diagnosis: anxiety and depression. Section P: Restraints and Alarms No restraints or alarms used. Section G: Bed mobility: Extensive assistance with two-person physical assist. Transfer: Extensive assistance with two-person physical assist. Review of Resident's #2's electronic care plan initiated 09/18/2019, revealed no evidence of a focus, objective, or interventions related to the use of a pommel cushion for safety and positioning. During an observation and interview on 05/16/2023 at 11:30 AM, revealed Resident #2 sitting in a wheelchair with pommel cushion in place underneath resident with a hump in the middle to keep him from sliding out. Resident stated it was to keep him from sliding out of his chair. During an interview on 05/17/2023 at 2:30 PM, the DON stated the MDS nurse was responsible for all other care plans including updating and adding new or acute problems. She stated she was ultimately responsible for ensuring that care plans were updated. The DON stated all positioning and safety devices should have been care planned. She stated not having accurate care plans could lead to residents not receiving the care that they need. 675866 Page 2 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/2023 at 2:40 PM, the MDS nurse stated she was responsible for all other care plans including updating and adding new or acute problems. She stated the bolster, bed alarm, and pommel cushion devices were used to prevent residents from falling and used for positioning and safety. She stated geri-chairs, bed alarms, bolsters, and wheelchair cushions should have been care planned. She stated she just missed them somehow. Residents Affected - Some Record review of the facility's policy titled Comprehensive revised October 2022 revealed: Policy: It is the policy. Of this facility. To develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet residents, medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidance: 1. The care planning process will include an assessment of the residents' strengths and needs and will incorporate the residents personal and cultural preferences and developing goals of care period services provided or arranged by the facility, as outlined by the Comprehensive care plan, they will be culturally competent, and trauma informed .3. The comprehensive care plan will describe, at a minimal, the following: a. The services that are to be furnished to attain or maintain the residents highest practical. Physical, mental, and psychosocial well-being .6. The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the residence comprehensive assessment period. The objectives will be utilized to monitor the resident progress period. Alternative interventions will be documented comma as needed period . 675866 Page 3 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0727 Level of Harm - Minimal harm or potential for actual harm 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 4 of 5 months reviewed. Residents Affected - Some The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 5 (11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023) of 151 days. 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 RN nursing schedule from 11/01/2022 to 03/31/2023, revealed no evidence of RN coverage on 11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023. During an interview on 05/17/23 at 02:42PM, the DON stated on 11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023 the facility did not have 8 hours of RN coverage. The DON stated the facility used agency staff to fill in when they need an RN. The DON stated the contracted agency sent a LVN instead of the requested RN, without notifying the DON of the change. The DON stated she was responsible for making and monitoring the schedule. The DON stated she did not feel there was a negative effect on residents, because she or one of the other RN's were available to come at any time and staff also had access to a RN thru telehealth consult services. The DON stated what led to the failure was the staffing agency not notifying when they scheduled a LVN instead of the requested RN. The DON further stated the facility lost one of their full-time weekend RNs due to the RN having to take medical leave. The DON also stated there was an inability to hire a fulltime weekend RN. The DON stated since August 2022 the facility had been searching for a full time RN and had not been able to hire a full time RN. Review of facility policy titled, Nursing Services-Registered Nurse (RN) dated October 2022 revealed The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day 7 days per week. 675866 Page 4 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for 1 of 1 kitchen reviewed, in that: The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: Record Review of facility MDS Resident 672 dated 05/15/2023 revealed, there were 31 out of 35 residents that ate from the kitchen. During observation on 05/15/2023 between 9:54 AM and 12:30 PM, the DA performed no hand hygiene. During the preparation of meals and while transporting trays to hallway, he was touching residents bare utensils, touching his face, pulling up his mask, and picking trash up off of the floor. There was also no wearing of gloves during these tasks. During observation on 05/15/2023 at 9:54 AM, of 1 of 1 pantry contained: 1 16 oz bag of coconut dated 8/6 with sell by Mar-04-2023. 1 clear bag of uncooked noodles not labeled dated 4/11/23. 1 clear bag of uncooked noodles not labeled dated 4/21/23. 1 clear bag of labeled Nilla dated 4/17. 1 sealed container labeled sugar with number 22233, with an empty cup for a scoop placed inside, and 1 container of butter with date of 4/25/23 During observation on 05/15/2023 at 10:00 AM, #1 of 5 freezers contained: 1 gallon clear freezer bag with what appeared to be frozen burritos, dated 9/27. (no year) 1 gallon clear freezer bag with what appeared to be frozen pancakes not labeled or dated. 1 gallon clear freezer bag with what appeared to be frozen tortillas not labeled or dated. 1 gallon clear freezer bag with what appeared to be frozen biscuits not labeled or dated. 675866 Page 5 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 1 gallon clear freezer bag with frozen labeled pastries, dated 3/21, (no year) and Level of Harm - Minimal harm or potential for actual harm 1 loaf of frozen wheat bread not dated. During observation on 05/15/2023 at 10:10 AM, Refrigerator #1 of 1 contained: Residents Affected - Some 1 bag of shredded lettuce with receive date of 5/9. 1 container of grape jelly not labeled and not dated 1 container labeled tortellini with alfredo dated 5/14/23 with no use by date. 1 container labeled cheese slices dated 5/12/23 with no use by date. 1 container labeled mechanical sausage and eggs was dated 5/15/23, and no use by date. 3 pkgs of egg mix dated 5/9/23 with no use by date. 1 opened container of BBQ sauce with a receive date of 5/5 with no open date. 1 opened container of Salsa with a receive date of 9/5 with no open date. 1 opened container of mayonnaise with a receive date of 5/2/23 with no open date. 1 opened container of [NAME] Slaw Dressing with a receive date of 2/7/23 with no open date. 1 opened container of Buttermilk Ranch Dressing with a receive date of 5/9/23 with no open date. 1 opened container of Italian Dressing with a receive date of 04/28/23 with no open date. 1 opened container of yellow mustard with a receive date of 04/14/23 with no open date. 1 opened container of Teriyaki sauce with a receive date of 8/6/22 with no open date. 1 small bag of what appeared to be shredded cabbage with no label dated 5/12. 1 small bag of what appeared to be shredded carrots with no label dated 5/12, and 1 clear bag contained 3 heads of brown lettuce with a smeared dated. During interview on 05/15/2023 at 10:30 AM, the DM stated all items should have an open date. The dates on the products were the received date, with no open dates. The lettuce she stated needed to be thrown away as it had turned brown. She stated, the dietary staff had training over all policy and procedures for hand hygiene as well as how to date all products whether receiving or opening. During interview on 05/15/2023 at 10:30 AM, the [NAME] stated the received date as well as the open and expiration/shelf-life date, should be on the food items where applicable. During interview on 05/15/2023 at 10:44 AM, the DA stated with the one date written on the clear 675866 Page 6 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gallon freezer bag, he would not have known if the date was the receiving or open date. The DA also stated, he has never marked the use by date on products but it was usually a 5-day shelf life. During observation and interview on 05/15/2023 at 12:24 PM, the Cook, after filling the warmer with resident trays, opened the door from the kitchen to hallway, with gloved hands, for the DA. He pushed the food warmer out to the hallway. The [NAME] then went to the pail of bleach water in the sink and dipped her gloved hands without drying. She then continued to serve on the line and stated, that was how she sanitized her hands. She proceeded to touch the residents bread for sandwiches as well as sliced cheese and the tops of plates During an observation and interview on 05/15/2023 at 12:30 PM, the DA, while on the serving line, ungloved and touched the unwrapped utensils. When interviewed, DA stated he was not to touch resident's utensils with ungloved hands. He stated he did not have to wear gloves if he did not want to. The DA was then observed to remove his facial mask while on the serving line without performing hand hygiene afterward. When the DA returned back to the serving line, observation of no handwashing, hand hygiene or gloves were observed. He then, as well, had handled residents sandwich bread, cheese, and tops of plates. During an interview on 05/16/23 at 10:02 AM, the DM stated her expectation was for kitchen staff to perform hand hygiene between kitchen tasks. She stated kitchen staff were to wear gloves at all times while on serving line. He stated the bleach water pail should never had been an option for hand sanitizing and had never been previously brought up in in-services. The DM stated the failure occurred with herself as DM and her expectations were for kitchen staff to date all products as needed, perform hand hygiene, and to follow the training and in-services regarding all kitchen expectations. During an interview on 05/16/2023 at 10:15 AM, the Admin stated the protocols for kitchen hand hygiene were to always wash hands when needed with changing of gloves for different tasks that are performed. She also stated the protocols were stated clearly in the policy for Received, Open and Use by dates and should always be monitored. The monitoring should have been done, first by the DM, and herself. The Admin stated the failures occurred was at the Cooks level as well as the DA. The kitchen staff and the DM all had been re-educated. The expectations she stated, was more education and in-services and for kitchen staff to perform hand hygiene, change out gloves, and having all products dated when received, open and/or use by dates. Record Review of facility In-service Record dated 01/05/2023, revealed: DM as presenter, addressed: DA and [NAME] attended, Items are not being dated After you open an item, put in bag, date and label it. Do not put anything in Fridge or Freezer without a date. Record Review of facility In-service Record dated 04/07/2023, revealed: DM as presenter, addressed: 675866 Page 7 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 DA and [NAME] attended, Level of Harm - Minimal harm or potential for actual harm When you open something, put remaining in Ziplock bag with label and date. Everything in Fridge and Freezer dated and labeled with date on viewed side. Residents Affected - Some Record Review of facility In-service Record dated 05/15/2023, revealed: DM as presenter, addressed: . DA and [NAME] attended, When you open an item, put open date. Label and date items you put in refrigerator and freezer using a sticker. . You can use a sharpie or a sticker, must be able to read. Record Review of facility In-service Record, Topic-Sanitation, dated 05/15/2023, revealed: DM as presenter, addressed: DA and [NAME] attended, Food prep sinks are not used for hand washing. Wash hands often. Before and after every task. When serving or get something on your hands, go to hand washing sink and wash hands, dry with paper towels. Wash hands if you touch anything, if wearing gloves, you must change gloves. Working with gloves on, is the same as bare hands. Cross contamination-for transfer of harmful bacteria from one person, object or place to another. Keep it Clean-wash hands with soap and hot water before and after handling food. Record Review of facility Dietary [NAME] Job Description dated 2023, Department of Food and Nutrition Services, Major Duties and Responsibilities: . .Ensures that food procedures are followed in accordance with established policies Additional Tasks . Follows appropriate safety and hygiene measures at all times to protect residents and themselves . 675866 Page 8 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 Follows established infection control policies and procedures . Level of Harm - Minimal harm or potential for actual harm Maintains food storage areas in a clean and properly arranged manner at all times. Residents Affected - Some Record Review of facility Dietary Aid Job Description dated 2023, Department of Food and Nutrition Services, Major Duties and Responsibilities; . Ensures that food procedures are followed in accordance with the stablished policies. The dietary aid assists with the service and delivery of food trays to designated areas, cleaning of the kitchen per established protocols, and proper washing and cleaning of food utensils and dishes . Additional Tasks: . . Follows appropriate safety and hygiene measures at all times to protect residents and themselves . . Follow established infection control policies and procedures. Record Review of facility Policy, Dry Storage and Supplies dated 2012, revealed: . 3. Dry bulk food (e.g., flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Scoops should not be left in food containers or bins. Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record Review of facility Policy, Storage Refrigerators dated 2012, revealed: . .5. food must be covered when stored, with a date label identifying what is in the container. 6. Frozen food that has been thawed will be used within three days of thawing. Record Review of facility Policy, food Safety dated 2012, revealed: . 11. 675866 Page 9 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 Gloves must be worn for preparation and service of foods that do not require further cooking. Level of Harm - Minimal harm or potential for actual harm Record Review of facility Policy, Maintaining a Sanitary Tray Line dated 2023, revealed: . .Compliance Guidelines: . Residents Affected - Some .3. During tray assembly, staff shall: . .c. Wear gloves when handling food items, particularly when direct contact between the hands and food occurs or when handling ready to eat food such as salads, fruits, sandwiches, breads, etc. d. Use gloves that fit properly. e. Wash hands before and after wearing or changing gloves. f. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the workstation. g. Change gloves after sneezing, coughing or touching face, hands, or hair with gloved hands. Record Review of facility Policy, Hand Washing dated 2012, revealed: . .5. Food preparation sinks are not to be used for hand washing. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 5/24/23), FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (D) . after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, 675866 Page 10 of 11 675866 05/17/2023 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 or drinking; . Level of Harm - Minimal harm or potential for actual harm (E) After handling soiled EQUIPMENT or UTENSILS; . Residents Affected - Some (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 675866 Page 11 of 11