Health inspection·June 16, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #1) of four residents reviewed for resident rights. The shower room door was left open and prevented Resident #1 from having privacy while bathing. This failure could place residents at risk for decreased dignity and privacy. Findings included: Review of Resident #1's quarterly MDS assessment, dated 02/17/23, revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses included anemia, heart failure, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, Non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, schizophrenia, and insomnia. She was understood and understood others. Her BIMS score of 4 out of 15 revealed she was severely cognitively impaired. Her Functional Status section indicated her self-performance was total dependence and she needed one-person physical assistance with bathing. Review of Resident #1's Care Plan, undated, reflected her focus was an ADL self-care performance deficit due to diagnoses of Alzheimer's and risk for self-care deficit (bathing, dressing, feeding). Her goals were to maintain current level of function, will be able to perform self-care needs, and will participate in self-care activities. Her interventions were bathing; the resident required no staff participation with bathing, required assistance with bathing/showering, evaluate her ability to perform ADLs/IADLs, evaluate functional abilities, and provide assistance with ADLs/IADLs as needed. Review of Resident #1's Fall Risk Evaluation, dated 01/30/23, revealed she had a low risk of falling. In an observation of Resident #1 on 06/09/23 at 8:45 AM revealed Resident #1 was in the shower room bathing herself without staff supervision. The shower room door was left open. Resident #1 was not visible from the hallway or any other area. The staff and residents did not see Resident #1 bathing through the open shower door. An interview with Resident #1 on 06/09/23 at 9:00 AM revealed she was confused and did not answer any of surveyor's questions. Page 1 of 15 675870 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/09/23 the Administrator stated LVN A was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding Resident #1 bathing unsupervised with the shower room door open. An interview with the ADON and DON on 06/09/23 at 7:04 PM revealed Resident #1 was able to bathe herself unsupervised. They stated they did not know if Resident #1 was care planned for unsupervised showers. They stated they were unaware Resident #1's quarterly assessment reflected; she required total dependence with one-person assistance with bathing. They stated they were unaware Resident #1's care plan reflected no staff assistance but required supervision. They stated Resident #1 preferred to bathe unassisted and unsupervised. They stated there were no risk to Resident #1 bathing unsupervised. They stated there was a privacy risk to Resident #1 because the shower room door was left open. They stated their expectation was for staff to keep the shower room door closed while a resident was bathing. They stated Resident #1 was confused and unaware of privacy concerns. They stated Resident #1 showering with the door open would not affect her but might bother other residents. On 06/09/23 the facility did not provide a policy regarding residents' right to privacy. 675870 Page 2 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 (Resident#1) of 4 residents reviewed for ADLs. Residents Affected - Few The facility failed to provide adequate assistance to Resident #1 during her shower. This failure could place residents at risk for poor personal hygiene, odors, and a decline in their quality of life. Findings included: Review of Resident #1's quarterly MDS assessment, dated 02/17/23, revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses included anemia, heart failure, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, Non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, schizophrenia, and insomnia. She was understood and understood others. Her BIMS score of 4 out of 15 revealed she was severely cognitively impaired. Her Functional Status section indicated her self-performance was total dependence and she needed one-person physical assistance with bathing. Review of Resident #1's Care Plan, undated, reflected her focus was an ADL self-care performance deficit due to diagnoses of Alzheimer's and risk for self-care deficit (bathing, dressing, feeding). Her goals were to maintain current level of function, will be able to perform self-care needs, and will participate in self-care activities. Her interventions were bathing; the resident required no staff participation with bathing, required assistance with bathing/showering, evaluate her ability to perform ADLs/IADLs, evaluate functional abilities, and provide assistance with ADLs/IADLs as needed. In an observation of Resident #1 on 06/09/23 at 8:45 AM revealed Resident #1 was in the shower room bathing herself without staff supervision. The shower room door was left open and Resident #1 was not visible from the hallway. There was staff and residents located in the hallway. An interview with Resident #1 on 06/09/23 at 9:00 AM revealed she was confused and did not answer any of surveyor's questions . On 06/09/23 the Administrator stated LVN A nurse was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding Resident #1 bathing unsupervised with the shower room door open. An interview with the ADON and DON on 06/09/23 at 7:04 PM revealed Resident #1 was able to bathe herself unsupervised. They stated they did not know if Resident #1 was care planned for unsupervised showers. They stated they were unaware Resident #1's quarterly assessment reflected; she required total dependence with one-person assistance with bathing. They stated they were unaware Resident #1's care plan reflected no staff assistance but required supervision. They stated Resident #1 preferred to bathe unassisted and unsupervised. They stated there were no risk to Resident #1 bathing unsupervised. They stated there was a privacy risk to Resident #1 because the shower room door was left open. They stated their expectation was for staff to keep the shower room door closed while a resident was bathing. They stated Resident #1 was confused and unaware of privacy concerns. They stated 675870 Page 3 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0677 Resident #1 showering with the door open would not affect her but might bother other residents. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Shower/Tub Bath, dated December 2022, reflected Purpose .Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. Residents Affected - Few 675870 Page 4 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #2) of five residents reviewed for quality of care. Residents Affected - Few The facility failed to assess and provide treatment for Residents #2's redness, moisture, and skin breakdown to the area underneath his neck skin fold. This failure could place residents at risk for increased pain and infection. Findings included : Review of Resident #2's Quarterly MDS assessment, dated 04/26/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had clear speech, was understood by others, and understood others. His BIMS score was 15, which reflected he was cognitively intact. His diagnoses included: cancer, anemia, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, and cholecystitis. His skin conditions reflected he had two stage 4 pressure ulcers (one pressure ulcer was present upon admission). His other skin problems were skin tears. His skin and ulcer/injury treatments were pressure reducing device for chair, pressure reducing device for bed, nutrition/hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings, and applications of ointments/medications. Review of Resident #2's physician orders, dated 06/09/23, revealed he did not have any orders for treatment to the area under his neck skin fold. Review of Resident #2's MAR, dated June 2023, revealed he did not receive treatment to the area under his neck skin fold. Review of Resident #2's care plan, undated, reflected his focus risk for impaired skin integrity. His goals were to identify his risk for impaired skin integrity and skin will remain intact. His interventions were to evaluate skin for areas of blanching or redness, monitor for moisture (apply barrier product as needed), and provide skin care per facility guideline and PRN. An observation and interview with Resident #2 on 06/09/23 beginning at 10:50 AM revealed redness, moisture, and skin breakdown underneath his neck skin fold. He stated he did not know the area underneath his neck fold was red, moist, or had skin breakdown. He stated the moisture underneath his neck fold was caused by sweat. He stated he did not receive treatment to the area underneath his skin fold. He stated the area was not painful. On 06/09/23 the Administrator stated LVN A was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding Resident #2's redness and skin breakdown under his neck skin fold. An interview with the ADON and DON on 06/09/23 at 7:04 PM, revealed Resident #2 was prone to moisture under his neck. They stated they were unaware he had redness and skin breakdown underneath his neck skin fold. They stated Nystatin would be added to the area underneath his neck to help reduce redness, prevent moisture, and prevent infection. They stated their expectation was for nursing to 675870 Page 5 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include all skin issues on his weekly skin assessments. They stated Resident #2 and his family had not complained about the area underneath his neck fold. They stated without treatment, he would be at risk for wounds and further skin breakdown. Review of facility policy, Wound Care, dated December 2022, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 675870 Page 6 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #2) of five residents reviewed for quality of care. Residents Affected - Few The facility failed to provide treatment to Residents #2's sacrum and right buttock. These failures could place residents with skin integrity issues at risk of sepsis, pain, worsening pressure ulcers, decreased quality of life, and a potentially life-threatening infection. Findings included : Review of Resident #2's Quarterly MDS assessment, dated 04/26/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had clear speech, was understood by others, and understood others. His BIMS score was 15, which reflected he was cognitively intact. His diagnoses included: cancer, anemia, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, and cholecystitis. His skin conditions reflected he had two stage 4 pressure ulcers (one pressure ulcer was present upon admission). His other skin problems were skin tears. His skin and ulcer/injury treatments were pressure reducing device for chair, pressure reducing device for bed, nutrition/hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings, and applications of ointments/medications. Review of Resident #2's physician orders, dated 05/22/23, revealed the following wound care orders; Stage 4 pressure wound to the right buttock: cleanse wound with normal saline, pat dry, apply collagen to wound bed, and cover with a dry dressing (every day shift for skin/wound support); and Stage 4 sacral wound: cleanse wound with normal saline, apply collagen to wound bed, and cover with a dry dressing (every day shift for skin/wound support). Review of Resident #2's MAR, dated June 2023, revealed he did not receive treatment to his right buttock and sacral wounds on 06/07/23 and 06/08/23. Review of Resident #2's care plan, undated, reflected his focus was a stage 4 pressure ulcer on his sacrum/coccyx. His goals were to show signs of healing, remain free from infection, and will have intact skin. His interventions were to administer treatments as ordered (monitor for effectiveness), follow facility policies/protocols for prevention/treatment of skin breakdown, and monitor dressing (every shift) to ensure it was intact and adhering (report lose dressing to treatment nurse). Review of Resident #2's wound evaluation and management summary, dated 05/22/23, reflected he had a stage 4 pressure ulcer on his sacrum and right buttock. His treatment plan was collagen sheet applied once daily for 30 days and gauze island with border applied once daily for 23 days. An interview with Resident #2 on 06/09/23 at 8:15 AM revealed he had a pressure sore in his buttocks area. He stated his pressure sore was covered with a dressing. He stated he did not remember the last time staff changed his dressing. He stated he was not experiencing pain. 675870 Page 7 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0686 Level of Harm - Minimal harm or potential for actual harm An observation of Resident #2 on 06/09/23 at 11:25 AM revealed the dressing on his sacrum and right buttock wound was dated 06/07/23. On 06/09/23 the Administrator stated LVN A was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding Resident #2's wound care. Residents Affected - Few An interview with the ADON and DON on 06/09/23 at 7:04 PM, revealed Resident #2 had a pressure ulcer on his sacrum. They stated he received daily wound care. They stated the nurses was responsible for completed his daily wound care. They stated they were unaware Resident#2's MAR reflected he had not received wound care since 06/06/23 and his bandage was dated 06/07/23. They stated their expectation for nurses was to provide wound care as ordered, document treatments on his MAR, and document the accurate date on his bandages. They stated Resident #2 was at risk of infection and worsened wounds if wound care was not provided. Review of facility policy, Wound Care, dated December 2022, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 675870 Page 8 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 residents received appropriate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for incidents and accidents. The facility failed to provide adequate supervision to Resident #1 while bathing in the shower room. This failure could place residents at risk for accidents and injuries. Findings included: Review of Resident #1's quarterly MDS assessment, dated 02/17/23, revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses included anemia, heart failure, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, Non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, schizophrenia, and insomnia. She was understood and understood others. Her BIMS score of 4 out of 15 revealed she was severely cognitively impaired. Her Functional Status section indicated her self-performance was total dependence and she needed one-person physical assistance with bathing. Review of Resident #1's Care Plan, undated, reflected her focus was an ADL self-care performance deficit due to diagnoses of Alzheimer's and risk for self-care deficit (bathing, dressing, feeding). Her goals were to maintain current level of function, will be able to perform self-care needs, and will participate in self-care activities. Her interventions were bathing; the resident required no staff participation with bathing, required assistance with bathing/showering, evaluate her ability to perform ADLs/IADLs, evaluate functional abilities, and provide assistance with ADLs/IADLs as needed. Review of Resident #1's Fall Risk Evaluation, dated 01/30/23, revealed she had a low risk of falling. In an observation of Resident #1 on 06/09/23 at 8:45 AM revealed Resident #1 was in the shower room bathing herself without staff supervision. The shower room door was left open. Resident #1 was not visible from the hallway or any other area. The staff and residents did not see Resident #1 bathing through the open shower door. An interview with Resident #1 on 06/09/23 at 9:00 AM revealed she was confused and did not answer any of surveyor's questions. On 06/09/23 the Administrator stated LVN A was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding Resident #1 bathing unsupervised with the shower room door open. An interview with the ADON and DON on 06/09/23 at 7:04 PM revealed Resident #1 was able to bathe herself unsupervised. They stated they did not know if Resident #1 was care planned for unsupervised showers. They stated they were unaware Resident #1's quarterly assessment reflected; she required total dependence with one-person assistance with bathing. They stated they were unaware Resident #1's 675870 Page 9 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan reflected no staff assistance but required supervision. They stated Resident #1 preferred to bathe unassisted and unsupervised. They stated there were no risk to Resident #1 bathing unsupervised. They stated there was a privacy risk to Resident #1 because the shower room door was left open. They stated their expectation was for staff to keep the shower room door closed while a resident was bathing. They stated Resident #1 was confused and unaware of privacy concerns. They stated Resident #1 showering with the door open would not affect her but might bother other residents. Review of facility policy titled, Shower/Tub Bath, dated December 2022, reflected Purpose .Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 675870 Page 10 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for two (Resident #2 and #3) of four residents observed for indwelling urinary catheters. 1. The facility failed to ensure Resident #2's catheter bag was not on the floor. 2. The facility failed to ensure Resident #3's foley catheter leg strap was in proper placement. These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: 1. Review of Resident #2's Quarterly MDS assessment, dated 04/26/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had clear speech, was understood by others, and understood others. His BIMS score was 15, which reflected he was cognitively intact. His diagnoses included: cancer, anemia, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, and cholecystitis. His appliances used was an indwelling catheter. Review of Resident #2's physician orders, dated 06/09/23, reflected, Foley Catheter 18F with 10ml balloon diagnosis for Foley Catheter use; stage 4 decubitus ulcer (start date 09/21/22). An observation and interview with Resident #2 on 06/09/23 at 8:23 AM revealed his foley catheter bag was on the floor. Resident #2 stated he was laying in the bed and did not know his catheter bag was on the floor. 2. Review of Resident #3's Quarterly MDS assessment, dated 05/21/23, revealed he was an [AGE] year-old male who admitted to the facility on [DATE]. He had clear speech, was understood by others, and understood others. His BIMS score was 14 out of 15 which meant he was cognitively intact. His diagnoses included: coronary artery disease, heart failure, hypertension, peripheral vascular disease, renal insufficiency, obstructive uropathy, diabetes mellitus, hyperlipidemia, and malnutrition. His appliances used was an indwelling catheter and he occasionally had urinary incontinence. Review of Resident #3's physician orders, dated 06/09/23, revealed the following orders: Foley catheter 16FR with 10ml balloon diagnosis; obstructive and reflux uropathy (start date 10/26/22) Monitor foley catheter leg strap for proper placement (every shift, PRN every shift, and PRN). Review of Resident #3's MAR, dated June 2023, revealed his foley catheter leg strap for proper placement was monitored on 06/09/23 during the 6:00 AM to 6:00 PM shift. Review of Resident #3's care plan, undated, reflected his focus was an indwelling catheter related to a diagnosis of obstructive and reflux uropathy. His goal was to show no signs/symptoms of urinary 675870 Page 11 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection. His intervention was the charge nurse will use adhesive catheter tubing holder to keep catheter tubing from pulling, catching, or prevent trauma. An observation and interview with Resident #3 on 06/09/23 at 10:00 AM revealed his foley catheter tubing was under his wheelchair behind the front left wheel. Whenever he would move in his wheelchair, the front and back wheel would roll over his catheter tubing. He stated he was experiencing pain in his pubis area related to the pulling of the foley catheter tubing. He stated he did not inform staff his foley catheter tubing was not strapped to his leg. He stated he did not inform staff he was in pain. An observation of RN B on 06/09/23 at 10:15 AM revealed he changed Resident #3's foley catheter tubing holder and applied a new catheter tubing holder to the left leg. He assessed Resident #3's pain and administered pain medication. The resident reported he was no longer experiencing pain. On 06/09/23 the Administrator stated LVN A was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding Resident #2's catheter. An interview with RN B on 06/09/23 at 5:22 PM revealed Resident #3 had a foley catheter. He stated a strap was used to keep Resident #3's catheter tubing from pulling. He stated he was unaware Resident #3's catheter tubing was hanging on the floor behind the front wheel of his wheelchair. He stated there were no risk to Resident #3 because his catheter tubing was reapplied to the tubing holder. He stated he assessed Resident #3's catheter and pain level. He stated Resident #3 complained of pain on 06/09/23. He stated he administered pain medication to Resident #3. An interview with the ADON and DON on 06/09/23 at 7:04 PM revealed Resident #3 used a wheelchair and had a foley catheter. They stated his catheter tubing was not supposed to be dragging on the floor behind the front wheel of his wheelchair. They stated he was supposed to have an attached to his catheter tubing to prevent pulling. They stated their expectation was for the nurses to ensure his catheter tubing and anchor were in place. They stated Resident #3 was at risk of infection and pain because his catheter tubing was not attached to his anchor. They stated Resident #2 had a foley catheter. They stated his catheter bag was supposed to be attached to the moveable part of his bed and below the pelvic area. They stated they did not know his catheter bag was on the floor in his room. They stated their expectation was for staff to ensure Resident #2's catheter bag was not on the floor. They stated he was at risk of infection because his catheter bag was on the floor. On 06/09/23 the facility did not provide a policy regarding catheter care prior to exit. 675870 Page 12 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

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 observation, interview 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 three (Resident #2, #3, #4) of four residents observed for infection control. Residents Affected - Some 1. LVN A failed to change gloves and perform hand hygiene during wound care for Resident #2. CNA C failed to perform hand hygiene before wearing gloves during incontinent care for Resident #2. 2. RN B failed to change gloves and perform hand hygiene during colostomy and incontinent care for Residents #3. 3. CNA D failed to sanitize pressure relieving devices (wedges) taken from a contaminated floor. CNA D proceeded to use the wedges on Resident #4. These failures could affect residents by placing them at risk of exposure to communicable diseases and infections. Findings Included: 1. Review of Resident #2's Quarterly MDS assessment, dated 04/26/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had clear speech, was understood by others, and understood others. His BIMS score was 15, which reflected he was cognitively intact. His diagnoses included: cancer, anemia, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, and cholecystitis. His bladder and bowel section revealed he had an indwelling catheter and always incontinent of bowel. His skin conditions reflected he had two stage 4 pressure ulcers (one pressure ulcer was present upon admission). His other skin problems were skin tears. His skin and ulcer/injury treatments were pressure reducing device for chair, pressure reducing device for bed, nutrition/hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings, and applications of ointments/medications. An observation of CNA C on 06/09/23 at 11:25 AM revealed she provided incontinent care to Resident #2. She removed his soiled brief and removed her gloves. She did not perform hand hygiene before she put on a clean pair of gloves. She then placed a clean brief under Resident #2. An observation of LVN A on 06/09/23 at11:35 AM revealed she washed her hands to put on a clean pair of gloves before removing Resident #2's old wound dressing (soiled with feces). She did not change gloves to clean the wound, pack the wound, or to apply the dry dressing. 2. Review of Resident #3's Quarterly MDS assessment, dated 04/30/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had clear speech, was understood by others, and usually understood others. His BIMS score was 8, which reflected he had moderate cognitive impairment. His diagnoses included: cancer, anemia, heart failure, hypertension, peripheral vascular disease, renal insufficiency, neurogenic bladder, urinary tract infection, diabetes mellitus, hyperlipidemia, arthritis, malnutrition, and anxiety disorder. His bladder and bowel section revealed he had an indwelling catheter and ostomy. 675870 Page 13 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation of RN B on 06/09/23 at 10:35 AM revealed he performed hand hygiene, wore a pair of clean gloves to remove Resident #3's colostomy bag, and disposed of colostomy bag into a trash bag. After changing removing the colostomy, he did not perform hand hygiene and change gloves. He wore the same gloves to clean Resident #3's stoma area with wipes and applied the new colostomy bag. He removed his gloves after applying the new colostomy bag and donned a clean pair of gloves. He opened Resident #3's brief to remove his supra-pubic catheter exit site dressing, cleaned the area, removed the brief, and placed a new brief on him with the same pair of gloves. Then he proceeded to apply dressing to Resident #3's supra pubic catheter exit site area while wearing the same gloves. 3. Review of Resident #4's Quarterly MDS assessment, dated 03/29/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had no speech, was rarely/never understood by others, and rarely/never understood others. His BIMS score reflected he was rarely/never understood. His level of altered consciousness fluctuated. His function status revealed he was total dependent and required two-person assistance. His diagnoses included: pneumonia, seizure disorder, and dysphagia. An observation of CNA D on 06/09/23 at 9:35 AM revealed she did not disinfect wedges before placing them in the bed with Resident #4. There were five wedges observed on the floor of Resident #4's room. CNA removed the wedges from the floor and placed them in the bed with Resident #4. She placed two wedges on each side of his body and placed one wedge between his legs. On 06/09/23 the Administrator stated LVN A was unavailable for an interview. He stated the surveyor could interview the ADON and DON regarding infection control. An interview with CNA C on 06/09/23 at 2:10 PM revealed she was supposed to perform hand hygiene before wearing clean gloves. She stated she did not know why she did not perform hand hygiene before donning clean gloves. She stated the clean area was contaminated because she did not perform hand hygiene before donning gloves. She stated Resident #2 was at risk of an infection because hand hygiene was not performed prior to donning gloves. An interview with CNA D on 06/09/23 at 2:22 PM revealed Resident #4's wedges were placed on the floor during incontinent care. She stated after incontinent care, she removed the wedges from the floor and placed them in the bed with Resident #4. She stated she did not disinfect the wedges prior to placing them in the bed with Resident #4. She stated the wedges contaminated Resident #4's bed linens. She stated the wedges exposed Resident #4 to germs and could cause an infection. An interview with RN B on 06/09/23 at 5:22 PM revealed he changed Resident #3's colostomy bag, brief, and catheter exit site dressing. He stated he perform hand hygiene prior to changing Resident #3's colostomy bag. He stated he did not perform hand hygiene after colostomy care because Resident #3 requested a brief change. He stated he should have performed hand hygiene between care. He stated the purpose of hand hygiene was to prevent the spread of germs. He stated Resident #3 was at risk for infection because hand hygiene was not performed between care. An interview with the ADON and DON on 06/09/23 at 7:04 PM revealed staff was routinely in-serviced regarding hand hygiene. They stated staff should perform hand hygiene before donning clean gloves. They stated hand hygiene should be performed before, during, and after incontinent care, colostomy care, and wound care. They stated CNA D should have disinfected the wedges before placing them in the bed with Resident #4. They stated the wedges should not have been placed on the floor. They stated LVN A, RN B, CNA C, and CNA D created infection control issues for Resident #2, #3, and #4. 675870 Page 14 of 15 675870 06/16/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of facility policy, Hand Washing/Hand Hygiene, dated December 2022, reflected: This facility considers hand hygiene he primary means to prevent the spread of infections .Use an alcohol-based hand rub or alternatively soap, and water for before donning sterile gloves . Residents Affected - Some 675870 Page 15 of 15