Health inspection·July 31, 2024

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 a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (ID #20) reviewed for comprehensive care plans. 1. Resident #20 had an indwelling urinary catheter in place when he was admitted to the facility and the indication for use, care, and monitoring of input and output were not included in the comprehensive care plan. 2. Resident #20 had an admission order for the antidepressant medication of Cymbalta 60 mg by mouth daily, and it was not included in the comprehensive care plan. 3. Resident #20's admission MDS Assessment, dated 4/19/24, had a care plan decision dated 4/24/24 to include all triggered care areas on the assessment summary in the comprehensive care plan. The care plan did not address all triggered care areas. These failures placed the residents at risk for not receiving necessary care and services to meet his individual needs and to promote a feeling of wellbeing during daily life within his living environment. The findings included: Review of Resident #20's admission Record, dated 7/31/24, revealed an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: hypothyroidism (thyroid disorder); diabetes; hyperlipidemia (high cholesterol); dementia; depression; hypertension (high blood pressure); atrial fibrillation (irregular heart beat); gastro-esophageal reflux disease (back-up of stomach acid into the throat); obstructive and reflux uropathy (urine flow is blocked through the ureter, bladder, or urethra and urine flows backward into the kidneys causing swelling); and benign prostatic hyperplasia (noncancerous enlargement of the prostate gland that pushes against the urethra and bladder, blocking the flow of urine). Review of Resident #20's active Physician Orders revealed an order dated 4/12/24 for Duloxetine 60 mg by mouth at bedtime related to depression (Cymbalta - antidepressant medication). There were orders dated 4/12/24 for catheter care every shift and 4/30/24 to change the indwelling urinary catheter every 30 days. Page 1 of 8 675866 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #20's Medication Administration Record, dated July 2024, revealed it included the order for Duloxetine 60 mg by mouth at bedtime at 8:00 PM, with the order start date of 4/12/24. The medication was documented as administered daily at bedtime as ordered. Review of Resident #20's Treatment Administration Record, dated July 2024, revealed it included the orders to change the Foley catheter (indwelling urinary catheter) every 30 days on the evening shift and to provide Foley catheter care every shift. The start dates were not documented. The catheter was documented as being changed on 7/29/24, and catheter care was documented as provided every shift daily. Review of Resident #20's admission MDS Assessment, dated 4/19/24, revealed the resident had a BIMS score of 8 out of 15 (mild cognitive impairment), had an indwelling urinary catheter, and received antidepressant medication. Review of Resident #20's admission MDS Assessment CAA Triggers Summary, signed and dated 4/25/24 by the DON, revealed the following triggered care areas: cognitive loss/dementia; visual function; communication; functional abilities for self-care and mobility; urinary incontinence and indwelling catheter; psychosocial well-being; falls; nutritional status; pressure ulcer/injury; psychotropic drug use; and pain. The CAA Triggers Summary documented a care plan decision, dated 4/24/24, to include the triggered care areas in the resident's care plan. Review of Resident #20's care plan dated 4/15/24 revealed documentation the resident had been placed on enhanced barrier precautions related to implanted medical device(s) indwelling urinary catheter. The goals were for the resident not to have a decline in psychosocial wellbeing related to being placed on EBP, not being restricted from out-of-room activities and remaining free from MDRO infections. Review of Resident #20's comprehensive care plan, dated 4/24/24, revealed it did not address the triggered care areas of communication, functional abilities for self-care and mobility, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, psychotropic drug use, and pain. The care plan did not address the indication for use for the indwelling urinary catheter, catheter care, monitoring input and output, or changing the catheter every 30 days per the physician's orders. The care plan addressed the resident's diagnosis of depression and documented an approach to administer medications as ordered and to monitor for side effects and effectiveness but did not address Resident #20's order for the antidepressant medication of Cymbalta. Observation on 7/29/24 at 11:00 AM revealed disposable gowns in a box on the wall outside the door to Resident #20's room. A sticker with EBP for enhanced barrier precautions was on the door frame to the side of the box. Resident #20 was lying on his back in bed, with his eyes open. The resident attempted to speak, but his voice was very soft and low and his speech was not understandable. A urinary catheter drainage bag was in a dignity bag hanging from the side of the bed frame. In an interview on 7/31/24 at 3:50 PM, the DON stated the ADON had been responsible for completing the MDS assessments, baseline care plans, and comprehensive care plans and had done it for the past 8 years. The DON stated the ADON had left during November 2023 and her positioned had not been filled. The DON stated the MDS Coordinator in a sister-facility had been completing the MDS assessments remotely. The DON stated she had been learning to do care plans and was now completing the comprehensive care plans. 675866 Page 2 of 8 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy and procedure for Comprehensive Care Plans, dated as revised 1/01/2024, revealed the following [in part]: 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . 675866 Page 3 of 8 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

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 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 1 of 1 kitchen reviewed. Residents Affected - Some 1. The floors were soiled with food particles and grease beneath the appliances and stainless-steel shelf units throughout the kitchen. This failure could place residents that received meals prepared in the facility kitchen at risk for foodborne illness and a decline in health status. The findings included: Observation on 07/29/2024 at 9:25 AM revealed food particles on the floor in the dry storage area and grease on the floor beneath the appliances and stainless-steel shelf units throughout the kitchen. In an interview on 07/29/2024 at 9:35 AM the Dietary Manager stated, the dietary staff is supposed to follow a daily cleaning schedule and initial the form after completing the cleaning tasks and I follow up to ensure the tasks are completed. She further stated, kitchen sanitation is important because it prevents foodborne illness and I do most of the cleaning myself. Record review of the daily cleaning logs dated July 2024, used for all the kitchen cleaning duties revealed all cleaning duties for the morning of 07/29/2024 had been completed and initialed by the kitchen staff that completed the cleaning. In an interview on 07/31/2024 at 2:10 PM, the DON stated, I expect the dietary staff to follow their cleaning schedule and company policy. In an interview on 07/31/2024 at 2:00 PM, the Administrator stated, dietary staff is supposed to follow company policy and the kitchen cleaning schedule. She further stated, by not following the kitchen cleaning schedule could put the residents at risk for foodborne illness . Review of the facility's Policy titled Sanitation Inspection dated, 01/01/2024 revised 01/17/2024 revealed [in-part]: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 675866 Page 4 of 8 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 2. Level of Harm - Minimal harm or potential for actual harm The department shall establish a sanitation program for food services based on applicable state and federal requirements. Residents Affected - Some 3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Inspections will be conducted but not limited to the following areas: a. Dry storage b. Freezer c. Refrigerator d. Dish room e. Pot wash f. Main production area g. Food preparation area h. General dietary observations Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected: Preventing Contamination from the Premises 675866 Page 5 of 8 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0812 3-305.11 Food Storage. Level of Harm - Minimal harm or potential for actual harm (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: Residents Affected - Some (1) In a clean, dry location. (2) Where it is not exposed to splash, dust, or other contamination . Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location. (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions. 675866 Page 6 of 8 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

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 reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1(Resident #21) of 8 residents reviewed for infection control, in that: Residents Affected - Few LVN A and LVN B failed to follow EBP (enhanced barrier precautions) signage instructions for Resident #21 by not donning a gown when providing incontinent care, and while performing wound care to Resident #21. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #21's electronic face sheet dated 7/31/2024 reflected he was a [AGE] year-old male admitted to the facility 0n 2/17/21. His diagnoses included: Colostomy (a surgically created opening in the large intestine which is sutured to an opening through the abdominal wall to create an alternate opening for feces to leave the body), diarrhea, cerebral infarct (a stroke that occurs due to disrupted blood flow to the brain causing parts of the brain to die off), hemiplegia and hemiparesis of right side (hemiplegia refers to complete paralysis of one side of the body and hemiparesis refers to partial weakness on one side of the body). Record review of Resident #21's active physician orders dated 7/31/2024 included an order dated 4/15/2024 which stated: May be placed on Enhanced Barrier Precautions related to colostomy and pressure injury. Record review of Resident #21's comprehensive person-centered care plan reflected a problem start date of 04/22/2024 reflected Problem: Enhanced Barrier precautions, Goal: Resident will remain free of MDROs, Interventions: gloves or gowns will be made available immediately outside of the resident's room. high contact activities include dressing, bathing providing hygiene, changing briefs, or assisting with toileting, care of devices such as catheters, central line, feeding tubes, tracheostomy, or ventilator tubes, and providing wound care. During an observation on 07/30/2024 at 1:43 PM of Resident #21's room revealed he had a sign which indicated he was on EBP at the head of his bed and gowns were available outside his door. Resident #21 was not interviewable. Review of the EBP sign on Resident #21's wall at the head of his bed reflected STOP, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs and assisting with toileting .Wound Care: Any skin opening requiring a dressing .indwelling medical devices. During an observation on 07/30/2024 at 03:41 PM wound care and incontinent care was provided by LVN A and LVN B on Resident #21. Both nurses sanitized their hands and donned gloves prior to the provision of incontinent care to Resident #21. LVN A and LVN B did not wear a gown. Gowns were observed to be available outside of the resident's room, and a sign that specified the precautions staff should take for EBP was posted at the head of Resident #21's bed. The 2 LVNS's removed the urine soiled 675866 Page 7 of 8 675866 07/31/2024 Stephenville Nursing and Rehabilitation 2311 West Washington Stephenville, TX 76401

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brief and performed peri-care. They removed their gloves and performed hand hygiene before donning new gloves and placing a new brief underneath the resident and turning him on to his rt side to perform wound care. LVN B provided the wound care and LVN A assisted. Neither LVN A nor LVN B donned a gown prior to performing wound care. In an interview on 07/30/2024 at 3:48 PM with LVN A and LVN B, both LVN A and LVN B stated they had recently been in-serviced on Enhanced Barrier Precautions. They stated that Resident's with a wound, ventilator, trach, or catheter or any other type of invasive medical device should be on EBP. LVN A and LVN B stated they failed to wear the gown because they were nervous with the surveyor watching them. In an interview on 07/31/24 at 3:52 PM, the DON/Infection Preventionist stated she it was her expectation that the LVN's should have worn a gown and other PPE as stipulated on the sign in the resident's room. She stated she had in-services on enhanced Barrier Precautions on 4/3/24, 4/22/24, and again on 5/10/24 for all staff. Copies of the policy and Inservice attendance sheets were provided by the DON. In an interview on 7/30/ 24 at 3:55 PM the facility administrator stated it was her expectation that the LVN's A and B should have worn a gown and other PPE as stipulated on the sign in Resident #21's room. The Administrator stated both LVN's should have known that they should wear a gown when providing care for Residents on EBP. She stated the failure occurred because both LVN's were nervous about performing the procedure in front of the surveyor. Record review of the facility policy and procedure titled Enhanced Barrier Precautions, dated Reviewed/Revised 04/01/2024, reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .all staff receive training at least annually and are expected to comply with all designated precautions .an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds .High-contact resident care activities include: . changing briefs or assisting with toileting .wound care; any skin opening requiring a dressing indwelling medical devices. Review of website https://www.cdc.gov/preventmdro on 7/20/24, revealed the following: Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status 675866 Page 8 of 8