Health inspection·February 8, 2024

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 ensure each resident was treated 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 for one (Resident #21) of three residents reviewed for dignity. The facility failed promote Resident #21's dignity by not covering his catheter's urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #21's Face Sheet dated 02/08/2024, reflected, an [AGE] year old-male admitted to the facility on [DATE] with diagnosis which included, Heart failure, Type-2 Diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel); Peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel); Diabetic retinopathy without macular edema (two common vision conditions related to diabetes) Record review of Resident #21's last quarterly MDS dated , 02/06/2024 reflected the resident had an indwelling catheter and a BIMs score of 15 indicating no cognitive impairment. Record review of Resident #21's Care Plan dated 10/22/2022, reflected, Focus: [Resident #21's] rights will be respected and maintained through the review date. Focus: [Resident #21] has an Indwelling Catheter, Intervention: Change Catheter and drainage bag based on clinical indications such as infection, obstruction, when the integrity of the closed system is compromised. An observation on 02/06/2024 at 11:29 AM revealed Resident #21's catheter bag hanging under his wheelchair uncovered. The bag, half full of yellow urine, was visible while the bag cover was also hanging under the wheelchair empty. Resident #21 was observed in the 300 Hall self-ambulating into the dining room and out of the dining room door on the 400 Hall and to his room. The dining room was full of residents awaiting lunch service. In an interview on 02/06/2024 at 11:31 AM, Resident #21 said the staff hung his catheter bag under his wheelchair. He said he did not recall who hung it there today. He said staff did not always put Page 1 of 23 675870 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0550 the bag in the cover but he preferred it to be covered. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services said catheter bags should be covered by a privacy bag to ensure the resident's privacy and dignity. She said staff were in serviced on residents' rights practices but could not recall when the last in-service was. She said it was all staffs responsibility to watch for those issues to ensure the resident's privacy. Residents Affected - Few In an interview on 02/07/2024 at 2:45 PM, the Administrator stated the catheter bags should be covered. She said the resident's privacy was important and nursing staff were responsible to ensure catheter bags were covered. She said not covering the bag could be a dignity concern for the resident. In an interview on 02/08/2024 at 11:16 AM, CNA E stated she worked on Resident #21's hall. She stated she tried to ensure catheter bags were covered. She said it was important to ensure resident dignity. She said all staff were responsible to make sure the catheter bags were covered. She said she had received dignity training but could not recall when the last time was. In an interview on 02/08/2024 at 11:16 AM, RN F said he worked on the hall where Resident #21 resided. He stated catheter bags should be in a privacy bag to ensure the resident's dignity. He stated he rounded often and expected CNAs to watch for that throughout their shift. A review of the facility's policy titled, Quality of Life - Dignity, reviewed December 2023, reflected, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered. 675870 Page 2 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Residents #53 and #58) of seventeen residents reviewed for call lights. Residents Affected - Few The facility failed to ensure Residents #53's and #58's call light were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Record review of Resident #53's face sheet, dated 02/08/2024, reflected he was an [AGE] year-old male who originally admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks); mild dementia, with psychotic disturbance (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life); Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells, Dizziness and giddiness; Abnormalities of gait and mobility; and repeat falls. Record review of Resident #53's quarterly MDS Assessment, dated 11/21/2023 reflected a BIMs score of 6 which indicated mild cognitive impairment. Record review of Resident #53's care plan, dated 04/21/2023, reflected the following: Focus: [Resident #53]is at risk for falls r/t HX Repeated falls Confusion, Unaware of safety needs . Goal: Will attempt to be free of falls through the next review date . Interventions: Call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Anticipate and meet my needs. Record review of Resident #58's face sheet, dated 02/08/2024, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Spondylosis with myleopathy (neurologic condition that develops insidiously over time as degenerative changes of the spine result in compression of the cord and nearby structures); Hypertension (when the pressure in your blood vessels is too high); Benign neoplasm of prostate (noncancerous enlargement of the prostate gland); Hypokalemia (potassium in the blood is too low); Age-related osteoporosis (bone density loss). Record review of resident #56's quarterly MDS Assessment, dated 01/07/2024 reflected a BIMs score of 6 which indicated mild cognitive impairment. Record review of Resident #58's care plan, dated 02/08/2022, reflected the following: Focus: [Resident #58] is at risk for falls r/t right-sided weakness. I have an actual fall with no injuries .Goal: Will not sustain serious injury through the review date .Interventions: Anticipate and meet my needs. Re-educate resident to turn call light on for help. Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Observation on 02/06/2024 at 10:56 AM revealed Resident #53 was lying in bed. The call button was 675870 Page 3 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0558 hanging on the wall behind the privacy curtain and out of reach of Resident #53. Level of Harm - Minimal harm or potential for actual harm Observation on 02/08/2024 at 08:20 AM revealed Resident #53 lying in bed. The call button was on the floor behind the bedside dresser and out of reach of Resident #53. Residents Affected - Few An observation and interview on 02/06/2024 at 10:51 AM, revealed Resident #58 was in bed. The call button was between the wall and the mattress at the foot end of the bed and out of reach of Resident #58. Resident #58 stated he used his call light when he needed assistance and was not sure why the button was at the foot of his bed. He said he was not able to reach the button but would yell for assistance if he needed it. In interview on 02/07/2024 at 08:55 AM, the LVN A stated call lights should be placed for all residents so they could call for assistance. She said she often reminded CNAs to place call lights in reach, but all staff were responsible to ensure they were accessible to residents. She said when the call light was not placed in reach residents were at risk of not having their needs met. In interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services said she expected call lights to be placed in reach for all residents at all times. She said they needed to be within reach of the residents, no matter what their functional capabilities were, and it was the resident's right to be able to call for assistance. In interview on 02/07/2024 at 02:45 PM, the Administrator said all staff were responsible to ensure call lights were placed in reach of residents. She said she expected the staff to follow the facility's policy which was to ensure residents had access to their call light. In interview on 02/08/2024 at 08:21 AM, CNA G said she Resident #53 was eating in his chair and she did have his call button placed near him. She said when he moved to the bed she should have placed the call button there. She stated call lights needed to be accessible to all resident to ensure they could call for assistance as needed. She stated placing call lights within reach was expected at all times. In interview on 02/08/2024 at 08:30 AM, the ADON stated call lights needed to be accessible to residents to ensure they could call for assistance when they needed it. She said the button needed to be near the resident even if they did not use it because it was their right to have a way to call for assistance. She stated staff were trained to place call lights and knew to do so. She said she rounded constantly and reminded staff of this regularly. Record review of the facility's policy titled, Resident Rights, reviewed December 2023, reflected, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility . These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility 675870 Page 4 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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 provide a private meeting space for residents' monthly council meetings for 6 of 6 residents reviewed for resident council. Residents Affected - Some The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation on 02/07/2024 at 10:30 AM, at a confidential group meeting held with 6 Resident Council participants revealed the meeting was planned and held in the facility's dining room. There were two doors leading to the dining room from the facility halls and a door in the dining room leading to the kitchen. Both doors to the dining room were closed and displayed signs, which reflected Resident Counsel Meeting. During the meeting, MA B and MA C entered the dining room and went to the kitchen, interrupting the meeting, on two separate occasions. A group interview on 02/07/2024 at 10:40 AM, with group meeting participants revealed their Resident Council Meetings were always held in the Dining Room. The stated staff were always coming through the Dining Room to the kitchen, during their meetings. They said that did not allow them to have private meetings. They said they had not complainted to anyone about it previously. In an interview on 02/07/2024 at 10:50 AM, MA B said she came into the dining room to bring and ice chest back to the kitchen. MA B said there was a sign on the dining room door noting a Resident [NAME] Meeting was going on, but she did not think it was an issue to enter the Dining Room because she has always done that. She said the Resident Council always met in the Dining Room and knows they should have a private space to do that. She said she did not believe she had any training to inform her of this. In an interview on 02/07/2024 at 10:58 AM, MA C said she did see the sign on the dining room door but had never been told not to enter when a Resident Counsel meeting was being held. She stated residents should have a private place to meet to ensure confidentiality of their meetings. In an interview on 02/07/2024 at 11:50 AM, the Activities Director stated Resident Council Meetings were always held in the Dining Room and signs were placed on the dining room entrances noting the meetings. She said staff knew they should not enter the dining room while Resident Council Meetings were being held to ensure resident privacy. She said staff were not in serviced on this but had been told verbally. She said residents had the right to meet in private without staff present. In an interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services stated residents should have a private place to meet and the dining room were not private. She said the facility was limited on space, but they needed to find a solution to ensure meetings were private. She said the signage placed on the doors in the dining room are not sufficient to ensure privacy for the meetings because staff still entered the dining room during meetings. In an interview on 02/07/2024 at 2:24 PM, the Administrator stated the Resident Council Meetings 675870 Page 5 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should be held in a private space for the residents, but the facility was limited on space. She said the Activities Director used signage on the dining room doors to control privacy but that did not always work. She said residents had the right to meet in private. Record review of the facility's policy titled, Resident Council Meetings, revised, 12/2023, reflected, Policy: This facility supports the rights of residents to organize and participate in resident groups in the facility. This policy provides guidance to promoting structure, order, and productivity in the group meetings. Definitions: Resident or family group is defined as a group of residents or residents' family members that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; support each other; plan resident and family activities; participate in educational activities; or for any other purpose. 675870 Page 6 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

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 observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #52) of 7 residents reviewed for comprehensive care plans. The facility failed to accurately define the quantity and type of alcohol the doctor's order authorized Resident #52 to safely consume daily on his care plan. The failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #52's face sheet, dated 01/08/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included: schizoaffective disorder, which is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania, benign neoplasm of the prostate, which is a noncancerous enlargement of the prostate gland, hyperlipidemia, which is an elevated level of lipids such as cholesterol and triglycerides in the blood, alcohol abuse with withdrawals, nicotine dependence (cigarettes), nerve root and plexus disorder, which is caused by pressure, pinching or stretching the nerve roots that exit or enter the spinal cord, chronic pain syndrome, secondary hypertension (high blood pressure that is caused by another medical condition), Atherosclerotic hearth disease of native coronary artery without angina pectoris, Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff and sometimes restricting blood flow to the organs and tissues, chronic ischemic heart disease which is heart weakening caused by reduced blood flow to the heart, Arthropathy (a joint disease, of which can be associated with a hematologic (blood) disorder or an infection), spondylolysis in the lumbar region, which is a stress fracture through the pars interarticularis of the lumbar vertebrae. The pars interarticularis is a thin bone segment joining two vertebrae, viral hepatitis C (a viral infection that causes liver swelling, called inflammation and can lead to liver disease), malignant neoplasm of bladder (bladder cancer) which occurs when cells in the bladder start to grow without control, cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), suspected exposure to COVID-19 (Coronavirus disease is an infectious disease caused by the SARS-CoV-2 virus, which is a strain of the species severe-acute-respiratory-syndrome-related coronavirus. Record review of Resident #52's MDS assessment, dated 11/16/2023, revealed his BIMS score was 12, which indicated moderate cognitive impairment. Resident #52 did not have any behaviors listed on his MDS assessment. Record review of Resident #52's Orders Summary Report, dated 02/07/2023 revealed an active telephone order for Resident #52 authorized by the Medical Director on 10/06/2023 with a start date of 10/07/2023. The telephone order by the Medical Director authorized that on 10/07/2023, Resident #52 may have 4-6 ounces of beer or wine every day shift. 675870 Page 7 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #52's care plan dated 12/07/2023 revealed it did not reflect the Medical Director's telephone order that that Resident #52 may have 4-6 ounces of beer or wine every day shift. On 02/07/2024 at 12:30 p.m., Resident #52 was observed in the facility with 1 open 16 ounce can of Bud-Light beer. Residents Affected - Few In an interview on 02/07/2024 at 12:35 p.m., The ADON stated that Resident #52 had a doctor's order for him to have 1 beer a day. The ADON stated Resident #52 was also care planned to have 1 beer a day during the day shift. In an interview on 02/07/2024 at 1:30 p.m., the ADON confirmed that the care plan for Resident #52 did not address that he may have 4-6 ounces of beer or wine every day shift per the Medical Director's active order for Resident #52. The ADON stated that she would contact the Medical Director for Resident #52 to request that Resident #52's order be changed. The ADON confirmed that Resident #52's care plan should reflect the active doctor's order for Resident #52 to consume 1 can of beer or wine per day according to the order. On 02/07/2024 at 1:45 p.m., a request was made for the ADON to unlock the Medication Storage Room. The ADON granted the request and unlocked the Medication Storage Room and opened the refrigerator. Inside the refrigerator there was a box of 12 16 ounce cans of Bud-Light beer inside the refrigerator on the door labeled with Resident #52's name on the box. In an interview with the Medical Director on 02/07/2024 at 2:14 p.m., she confirmed that she approved for Resident #52 to have 1 beer a day during the day shift. She stated that she approved an active order for Resident #52 to have 1 beer a day, but did not know that the active order reflected, may have 4-6 ounces of beer or wine per day during the day shift. She was informed that according to the Bud-Light website, the company does not produce 4-6 ounces of beer. The Medical Director stated that her staff must have called in the incorrect order, and she would change the telephone order and notify the facility with the updated order. The Medical Director stated that she would change the current active order for Resident #52 to reflect that he may have 1 can of beer a day up to 16 ounces and limit wine to 6 ounces a day. The Medical Director stated that although the current active telephone order was incorrect, she did not feel as though there was any harm done to Resident #52 after consuming the 1 can of 16 ounce beer. She stated that Resident #52 has not exhibited any behavioral or health issues or concerns since his active current order to consume beer daily. Observation and interview on 02/07/2024 at 3:45 p.m., Resident #52 was observed in the facility sitting in his wheelchair in the hallway. Resident #52 did not appear to be in any distress, and he stated that he was feeling good and did not have any complaints. Record review of Resident #52's Orders Summary Report dated 02/08/2024 revealed an updated active telephone order for Resident #52 signed and dated by the Medical Director on 02/07/2024 at 6:47 p.m. The active telephone order reflected Resident #52, may have 1 can of beer a day up to 16 ounces, limit wine to 6 ounces a day for every day shift. In an interview on 02/08/2024 at 9:16 a.m., with the [NAME] President of Clinical Services, she stated that she was unaware that Resident #52's care plan did not have information regarding his approved doctor's order to consume alcohol daily. She stated that it is the duty of the Director of Nursing to ensure that the most recent and updated information for each resident is in their care plan. 675870 Page 8 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated that the facility no longer has a Director of Nursing due to the previous person that held the position resigning from the agency. She reported that she has been fulfilling the role of the Director of Nursing at the facility until a replacement Director of Nursing is hired at the facility. She was advised that Resident #52 was observed with a 16 ounce can of beer on 02/07/2024 although his doctors order reflected that he may have 4-6 ounces of beer or wine every day shift. She stated that there have not been any notifications from staff of Resident #52 having behavior issues due to his consumption of alcohol. She stated that she feels that Resident #52 has not received any harm from drinking alcohol daily . In an interview on 02/08/2024 at 9:30 a.m. with the Social Worker, she confirmed that Resident #52 had a doctor's order for him to have 1 can of beer per day on the day shift. The Social Worker stated that the staff on the floor have provided Resident #52 with his beer every day shift per his doctor's order. She stated that there have not been any concerns brought to her attention regarding Resident #52 having any behavioral issues after his daily consumption of alcohol. The Social Worker stated that it appears that Resident #52 has not had any adverse reactions to his daily consumption of alcohol. In an interview on 02/08/2024 at 10 a.m. with the Administrator, she confirmed that Resident #52 had a doctor's order for him to have 4-6 ounces of beer or wine per day during the day shift. She stated that Resident #52's family will purchase the beer for him. The Administrator stated that she does not know when Resident #52's family purchased and brought the current pack of beer to the facility. The Administrator stated that she felt that there was no harm done to Resident #52's well-being after drinking the 16 ounce beer he was observed drinking on 02/07/2024. The Administrator stated that Resident #52 is given an assessment by staff after his daily consumption of beer and there have not been any problems. She stated that Resident #52 is safe in a wheelchair and has not had any history of becoming drunk and belligerent after consuming the alcohol and he has not had any history of falls. The Administrator stated that Resident #52's care plan should reflect that the doctor approved for him to have 1 beer a day . She stated that she was unaware that Resident #52's care plan did not include that he may consume 1 beer per day. In an interview with Resident #52 on 02/08/2024 at 1:03 p.m., he stated that he had a doctor's order for him to have 1 can of beer a day. Resident #52 stated that he prefers to drink beer and does not drink wine. He stated that his family member purchases his beer for him and brings it to the facility. He stated that he is limited to 1 beer per day but would prefer 2 peers per day, but the facility will only has allowed him 1 beer per day. Resident #52 stated that he does not know how many ounces of beer his doctor approved for him to have per day. He stated he has been educated by staff about alcohol consumption and the effects of drinking alcohol with his health conditions. Resident #52 stated that when he drinks 1 beer per day and his consumption of alcohol has not had any affects to his body, or his behavior and it just makes him feel good. Record review of the facility's policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting last revised in March 2023, revealed The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and 675870 Page 9 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0656 psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675870 Page 10 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities in that they failed to ensure physician orders were followed for one resident (Resident #64) of 4 residents reviewed for enteral nutrition. 1. LVN A failed to check for residual volume prior to medication administration for Resident #64 These failures could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures. Findings included: Review of Resident #64's face sheet, dated 02/08/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Her diagnoses included Gastrostomy status (an opening in the stomach at the abdominal wall made surgically to introduce food), dementia, Alzheimer's, and major depressive disorder. Review of Resident #64's annual MDS Assessment, dated 01/11/24, revealed Resident #64 BIMS score was blank which indicated severe cognitive impaired. Resident # 64 required extensive to total assistance with ADLs with two persons assist. Further review revealed Resident #64 had a feeding tube. Record review of Resident #64's medication administration and treatment record revealed an order with a start date of 11/14/23 which indicated, Enteral Feed Order every shift Check Residual prior to feeding if greater than 150cc return contents and HOLD feeding and notify MD. Observation on 02/06/10 at 09:48 am revealed LVN A administering medication through the feeding tube. LVN A got the following medications ready, Potassium chloride 10% (20meq) 15 ml, gabapentin 300 mg 1 capsule, prostat 30 cc, carvedilol 3.125 mg 1 tablet, one-daily multi-vitamins 1 tablet and, stool softener 100 mg 1 tablet. Staff LVN A crushed the tablet medications and mixed with water. The resident's feeding tube was infusing, and she paused the feeding tube and then disconnected the feeding tube from the resident. LVN A then checked gastrostomy tube placement with a stethoscope, for placement and flushed with 30cc of water. LVN A administered each medication individually and flushed with 5cc of water after medication administration. In an interview on 02/06/24 at 09:26 am with LVN A, she stated regarding checking the resident's residual, she stated she forgot, and she was supposed to check to make sure the resident did not have more than the recommended amount which could lead to aspiration, and/or vomiting. LVN A stated there were parameters that the staff was supposed to follow when checking for residual, and if the resident had more than the recommended amount, she was supposed to inform the primary care provider and hold any feeding or medication administration. In an interview on 02/07/24 at 12:08 pm with the [NAME] President for Clinical Services, she stated LVN A was supposed to check the resident's residual before medication administration to make sure 675870 Page 11 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident was not being overfed which could lead to aspiration. She stated the nurse had been in-serviced on medication administration. Record review of facility policy revised 2023 and titled Administering the Medications through the Enteral Tubing reflected, Step in the Procedure . 20. Check gastric residual volume (GRV) to assess for tolerance of enteral feeding. 21. When correct tube placement and acceptable GVR have been verified, flush tubing with 15-30 ml warm or room temperature water (or prescribed amount). 675870 Page 12 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for one (Resident #36) of three residents on psychoactive medication in that: The facility failed to ensure that Residents #36 had orders for psychotropic medications lorazepam (brand name Ativan) that did not contain PRN orders beyond 14 days without an end date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. The findings include: Review of Resident #36's face sheet, dated 02/08/24, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, dementia, mood disorder, major depression, anxiety, and Alzheimer's. Review of Resident #36's quarterly MDS Assessment, dated 01/25/24 revealed the Residen#36's BIMS score of 00 indicating severe cognitive impairment. The MDS further reflected Resident#36 had a diagnosis of anxiety disorder. Review of Resident #36's care plan dated 07/09/18 reflected, focus have mood problem r/t dx Anxiety Disorder, Disease Process (Depression). I participate in an outpatient program at . Behavioral Hospital. Goal, I will have improved mood state (happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the next review date. Intervention, Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of Resident #36's orders with a start date of 12/09/23 on 02/08/24 reflected an order of Lorazepam oral tablet 0.5 mg give 1 tablet by mouth every 4 hours as needed for anxiety/agitation. In an interview on 02/08/24 at 12:50 pm the ADON acknowledged that the order for Resident #36's Lorazepam 0.5 mg PRN had been in the MAR since December 2023 and Resident#36 had been getting the medications until now as needed for anxiety. The ADON stated she was the one responsible to make sure the residents who were on PRN antipsychotic medications were assessed every 14 days for the resident to continue with the medication. The ADON stated she did not know Resident #36's PRN Lorazepam required a new order after 14 days because the resident was on hospice. The ADON stated the PRN medication was required to be reviewed to determine if the resident required the medication. The ADON stated she will reach out to the resident's primary care provider to inform them of the need for the medication to be reviewed. In an interview on 02/08/24 at 01:15 pm with the [NAME] President for clinical services, she stated all PRN Psychotropic medications were supposed to be re-evaluated every 14 days by the resident's primary care provider and determine if the resident was to continue with the medication. She 675870 Page 13 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0758 conformed the medication had not been re-evaluated. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy reviewed December 2023 titled antipsychotic or neuroleptic medication use reflected, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environment causes of behaviors symptoms have been identified and addressed.14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. Residents Affected - Few 675870 Page 14 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

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 safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure nonfood-contact surfaces were kept free of dust and other debris. These failures could place residents, who received food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation and interview with the Dietary Manager on 02/06/2024 at 9:30 AM revealed a vent over the plate warmer and food prep area. The vent grate displayed a build up of dust and fluttering fuzz. The Dietary Manager stated Maintenance cleaned the vents. She said dust could dislodge and contaminate the food in prep area. A utensil rack over the food prep area was observed with dust and fuzz. The vent over the rear exit to the kitchen was observed with dust and fuzz. Dust and grease were observed on electric plugs near the stove. Five fire sprinklers in the kitchen were observed with dust, grease and fuzz build up. The light cover in the dry food storage pantry was observed with dead bugs inside the cover. The Dietary Manager stated each area of concern could cause possible food contamination. Interviewed the with Maintenance Director on 02/07/2024 at 8:36 AM. He stated he had logbooks at the nurses station where staff enters requests. The log was reviewed from 1/31/24-present and there was no note on kitchen cleaning. He stated he checked the log daily and addresses concerns, and if someone asks him to do something he asks them to log it. He stated the vents in the kitchen were to be cleaned by the kitchen staff. He did not know who was responsible for cleaning the sprinkler heads and he thought the kitchen should be responsible for cleaning the sprinkler heads. Observed and interviewed with the Dietary Manager on 02/07/2024 at 2:50 PM revealed that areas of concern were cleaned. She stated the Maintenance Director cleaned the vents and even though she was not responsible, she wiped the fire sprinklers. She provided the kitchen cleaning schedule and this surveyor observed that the plugs were not included on the schedule. She stated she doesn't have a schedule for the vents, but maintenance should have a schedule. She stated maintenance cleans the vents once a week. Interviewed with the Maintenance Director on 02/07/2024 at 2:55 PM, he stated he cleaned the filters and vents in the kitchen every week. He doesn't keep a written schedule or log for cleaning the vents. He cleaned the vents in the kitchen after the concern was expressed to the Dietary Manager. Interviewed with the Dietitian on 02/07/2024 at 3:02 PM reveled she didn't know if there is a log for cleaning the vents. She doesn't know if the vents are cleaned at the beginning of the week or the end of the week. Her expectation is that the vents are cleaned because they could cause contamination. Interviewed with the Administrator on 02/07/2024 at 3:15 PM revealed the vents should be cleaned weekly or when needed. No one has ever brought to her attention that the vents were dirty. She doesn't 675870 Page 15 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some know if there is a cleaning schedule for cleaning the vents. There is a log that any department head can put concerns in that they want maintenance to take care of and the logs are looked at daily. Record review of Food and Drug Administration Food Code dated 2017 section 4-601.11 revealed, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 675870 Page 16 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #27 and Resident #52) of 7 residents reviewed for resident medical records. The facility failed to accurately define the quantity of alcohol (beer or wine) authorized for 2 residents (Resident #27 and Resident #52) to safely consume daily per their physician orders. This failure could place residents at risk for the inappropriate care due to inaccurate or incomplete medical and clinial records as ordered by their physician. Findings included: 1. Record review of Resident #52's face sheet, dated 01/08/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included: schizoaffective disorder, which is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania, benign neoplasm of the prostate, which is a noncancerous enlargement of the prostate gland, hyperlipidemia, which is an elevated level of lipids such as cholesterol and triglycerides in the blood, alcohol abuse with withdrawals, nicotine dependence (cigarettes), nerve root and plexus disorder, which is caused by pressure, pinching or stretching the nerve roots that exit or enter the spinal cord, chronic pain syndrome, secondary hypertension (high blood pressure that is caused by another medical condition), Atherosclerotic hearth disease of native coronary artery without angina pectoris, Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff and sometimes restricting blood flow to the organs and tissues, chronic ischemic heart disease which is heart weakening caused by reduced blood flow to the heart, Arthropathy (a joint disease, of which can be associated with a hematologic (blood) disorder or an infection), spondylolysis in the lumbar region, which is a stress fracture through the pars interarticularis of the lumbar vertebrae. The pars interarticularis is a thin bone segment joining two vertebrae, viral hepatitis C (a viral infection that causes liver swelling, called inflammation and can lead to liver disease), malignant neoplasm of bladder (bladder cancer) which occurs when cells in the bladder start to grow without control, cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), suspected exposure to COVID-19 (Coronavirus disease is an infectious disease caused by the SARS-CoV-2 virus, which is a strain of the species severe-acute-respiratory-syndrome-related coronavirus. Record review of Resident #52's MDS assessment, dated 11/16/2023, revealed his BIMS score was 12, which indicated moderate cognitive impairment. Resident #52 did not have any behaviors listed on his MDS assessment. Record review of Resident #52's Orders Summary Report, dated 02/07/2023 revealed an active telephone order for Resident #52 authorized by the Medical Director on 10/06/2023 with a start date of 10/07/2023. The telephone order by the Medical Director authorized that on 10/07/2023, Resident #52 may have 4-6 ounces of beer or wine every day shift. 675870 Page 17 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #52's care plan dated 12/07/2023 revealed it did not reflect the Medical Director's telephone order that that Resident #52 may have 4-6 ounces of beer or wine every day shift. 2. Record review of Resident #27's face sheet, dated 08/25/2023, revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #27 readmitted to the facility on [DATE]. His diagnoses included: anxiety disorder, schizoaffective disorder(mental health condition including schizophrenia and mood disorder symptoms, Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder and symptoms may occur at the same time or at different times), dyspnea (a sensation of running out of the air and of not being able to breathe fast enough or deeply enough), obesity, abnormal weight gain, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hemorrhoids (when the veins or blood vessels in and around your anus and lower rectum become swollen and irritated), cataracts (clouding of the lens of the eye in an area that is normally clear), allergic rhinitis (inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold, or flakes of skin from certain animals), anemia (low iron levels), insomnia (sleep disorder that can make it hard to fall asleep or stay asleep), constipation (condition in which a person has uncomfortable or infrequent bowel movements), vitamin deficiency (long-term lack of a vitamin), other retention of urine (a condition in which a person is unable to empty all the urine from the bladder), obstructive and reflux uropathy (urine cannot flow through the ureter, bladder or urethra due to some type of obstruction), benign prostatic hyperplasia with lower urinary tract symptoms(a condition in men in which the prostate gland is enlarged and not cancerous), edema (swelling caused by too much fluid trapped in the body's tissues), secondary hypertension (high blood pressure that's caused by another medical condition), hyperlipidemia (elevated level of lipids - like cholesterol and triglycerides in blood), chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in patients with COPD), COPD is a group of diseases that cause airflow blockage and breathing-related problems, metabolic encephalopathy (a problem in the brain), acute respiratory failure with hypoxia (Respiratory failure is a condition where there is not enough oxygen in the tissues in the body), hypo-osmolality and hyponatremia (produced by retention of water, by loss of sodium or both), hypokalemia (lower than normal potassium in the blood stream), acute kidney failure (when the kidneys suddenly become unable to filter waste products from the blood), and contact with and exposure to COVID-19, Coronavirus disease is an infectious disease caused by the SARS-CoV-2 virus, which is a strain of the species severe-acute-respiratory-syndrome-related Coronavirus. Record review of Resident #27's MDS assessment, dated 01/13/2024, revealed his BIMS score was 13, which indicated that he was cognitively intact. Resident #27 did not have any behaviors listed on his MDS assessment. Record review of Resident #27's care plan dated 08/25/2023, revealed that he was prescribed psychotropic medications (psychotropic medications are medications that affect the mind, emotions, and behavior.) for behavior management and bipolar and had a physician order to have 4-6 ounces of beer or wine every day. Record review of Resident #27's Orders Summary Report dated 02/07/2023 revealed an active telephone order for Resident #27 authorized by the Medical Director on 08/25/2023 with a start date of 08/26/2023. The telephone order by the Medical Director authorized that on 10/07/2023, Resident #27 may have 4-6 ounces of beer or wine every day shift. 675870 Page 18 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #27's Orders Summary Report dated 02/07/2024 revealed an updated active telephone order for Resident #52 signed and dated by the Medical Director on 02/07/2024 at 7:28 p.m. The active telephone order reflected that Resident #27, may have 1 can of beer a day up to 16 ounces, limit wine to 6 ounces a day for every day shift. Record review of Resident #27's Progress Notes revealed the ADON's entry dated 02/07/2024 at 7:31 p.m., reflected effective 02/08/2024, Resident #27 may have 1 can of beer a day up to 16 ounces and limit wine to 6 ounces a day. The ADON Nurses Note reflected , Medical director called and was able to give direction for this resident as well at this time the orders are to discontinue may have 6-8 ounces of beer every day. New orders to update to may have 1 can of beer a day up to 16 ounces. Limit wine to 6 ounces a day. 3. In an interview on 02/07/2024 at 12:35 p.m., the ADON stated that stated that Resident #52 has a doctor's order for him to have 1 beer a day. The ADON stated that Resident #52 also is care planned to have 1 beer a day during the day shift. In an interview on 02/07/2024 at 1:30 p.m., the ADON confirmed that the care plan for Resident #52 did not address that he may have 4-6 ounces of beer or wine every day shift per the Medical Director's active order for Resident #52. She stated that Resident #27 has the doctor's orders on his care plan and also has the same order as Resident #52, which reflected that he may have 4-6 ounces of beer or wine every day shift, The ADON stated that the family members of Resident #52 purchase the beer for him and purchase different variety of boxes of beer to the facility. She stated that Resident #27's family member will purchase his alcohol for him, but he has not had any alcohol brought into the facility in a long time. The ADON stated that she would contact the Medical Director for Resident #52 to request that Resident #52's order be changed. On 02/07/2024 at 1:45 p.m., the ADON unlocked door of the Medication Storage Room and opened the refrigerator. Inside the refrigerator there was a 12 can box of 16 ounce Bud-Light beer cans inside the refrigerator on the door labeled withResident #52's name on the box. The box of Bud-Light beer that included 11 of 12 cans of 16 ounce beer cans. The ADON stated that the Nurse on duty has access to the key for the Medication Storage Room. There were not any other alcoholic beverages observed in the refrigerator. In an Interview with the Medical Director 02/07/2024 at 2:14 p.m., she confirmed that she approved for Resident #52 to have 1 beer a day during the day shift. She stated that she approved an active order for Resident #52 to have 1 beer a day, but did not know that the active order states, may have 4-6 ounces of beer or wine per day during the day shift. She was advised that according to the Bud-Light website, the company does not produce 4-6 ounces of beer. The Medical Director stated that her staff must have called in the incorrect order, and she would change the telephone order and notify the facility with the updated order. The Medical Director stated that she would change the current active order for Resident #52 to reflect that he may have 1 can of beer a day up to 16 ounces and limit wine to 6 ounces a day. The Medical Director was informed that Resident #27 had the same active order as Resident #52 and she stated that although she is not the physician for Resident #52 , she would call the facility and update his physician orders as well to reflect that he may have 1 can of beer a day up to 16 ounces and limit wine to 6 ounces a day. The Medical Director stated that although the current active telephone order was incorrect, she did not feel as though there was any harm done to both residents. She stated that according to the facility staff both residents (Resident #27 and Resident #52) have not exhibited any behavioral or health issues or concerns with their current active orders to consume beer daily. 675870 Page 19 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/07/2024 at 3:45 p.m., Resident #52 was observed in the facility sitting in his wheelchair in the hallway. Resident #52 did not appear to be in any distress, and he stated that he was feeling good and did not have any complaints. In an interview on 02/08/2024 at 9:16 a.m., with the [NAME] President of Clinical Services, stated that was informed that Resident #52 was observed with a 16 ounce can of beer on 02/07/2024 although his doctors order reflected that he may have 4-6 ounces of beer or wine every day shift. She stated that there have not been any notifications from staff that Resident #52 having behavior issues due their consumption of alcohol. She stated that she feels that Resident #27 and Resident #52 has not received any harm from drinking alcohol daily. She was informed that Resident #27 has the same doctor's order that reflected that he may have 1 can of beer a day up to 16 ounces and limit wine to 6 ounces a day. In an interview on 02/08/2024 at 9:30 a.m. with the Social Worker, she confirmed that 2 residents (Resident #27 and Resident #52) have active doctor's orders for them to have 1 can of beer per day on the day shift. The Social Worker stated that the staff on the floor provided Resident #52 with his beer every day shift. She stated that there have not been any concerns brought to her attention regarding both residents (Resident #27 and Resident #52) having any behavioral issues after his daily consumption of alcohol. The Social Worker stated that it appears that both residents (Resident #27 and Resident #52) have not had any adverse reactions to after the consumption of alcohol. In an interview on 02/08/2024 at 10 a.m. with the Administrator, she confirmed that both residents (Resident #27 and Resident #52) have a doctor's order for them to have 4-6 ounces of beer or wine per day during the day shift. She stated that both residents' family will purchase the beer for them. She stated that she does not know when Resident #52's family brought the current pack of beer to the facility. The Administrator stated that she felt that there was no harm done to Resident #52's well-being after drinking the 16 ounce beer he was observed drinking on 02/07/2024. The Administrator stated that Resident #52 is given an assessment by staff after his daily consumption of beer and there have not been any problems. She stated that Resident #52 is safe in a wheelchair and has not had any history of becoming drunk and belligerent after consuming the alcohol and he has not had any history of falls. The Administrator stated that Resident #27 has not had any odd or unusual behaviors after he has drank alcohol. She reported that staff assess and monitor each resident that has consumed alcohol per their doctor's orders to ensure their safety throughout the day. In an interview with Resident #52 on 02/08/2024 at 1:03 p.m., he stated that he has a doctor's order for him to have 1 can of beer a day. Resident #52 stated that he prefers beer and does not drink wine. He stated that his family member purchases his beer for him and brings it to the facility. He stated that he is limited to 1 beer per day but would prefer 2 peers per day, but the facility will only allow him 1 beer per day. Resident #52 stated that he did not know how ounces of beer his doctor approved for him to have per day. He stated he was educated by staff about alcohol and the effects of drinking alcohol with his health conditions. Resident #52 stated that when he drinks 1 beer per day it does not have any affects to his body, or his behavior and it just makes him feel good. In an interview with Resident #27 on 02/08/2024 at 1:25 p.m., he confirmed that he has a doctor's order for 1 beer or wine per day but did not know the specifics of the quantity of each he was authorized to have per day. He stated that in the past his family member purchased his alcohol for him and brings it to the facility for him to have. Resident #27stated that due to financial reasons, his son has not been able to purchase any alcoholic beverages for him. He stated that when he had alcohol, he would receive 1 can of beer per day by staff and the alcohol is locked in the refrigerator in a 675870 Page 20 of 23 675870 02/08/2024 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few storage room located near the Nurses Station. Resident #27 stated that he was educated by the staff about the warnings of drinking alcohol. He stated that he has not been drunk or acted out or anything like that when he would drink alcohol in the facility. Record Review of the facility's policy reviewed on December 2023, Quality of Life - Dignity, revealed that the policy did not include information relating to physician orders. 675870 Page 21 of 23 675870 02/08/2024 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 1 (Resident #26) of 3 residents reviewed for infection control. Residents Affected - Few The facility failed to ensure Resident #26's catheter bag was kept off the floor while in the dining room. This failure could place residents at risk of contracting or spreading an infection. Findings included: Record review of Resident #26's Face Sheet dated 02/08/2024, reflected, a [AGE] year-old male admitted to the facility 02/27/2020 with diagnosis which included Malignant neoplasm of prostate (prostate cancer); Anemia (when your blood produces a lower-than-normal amount of healthy red blood cells); Obstructive and Reflux Uropathy (when your urine can't flow (either partially or completely) through your ureter, bladder, or urethra); Blindness in one eye, low vision in the other eye; Cognitive Communication Deficit (difficulty with thinking and how someone uses language); and Benign prostatic hyperplasia without lower urinary tract symptoms (a weak urine stream, and leaking or dribbling of urine). Record review of Resident #26's last quarterly MDS dated , 12/24/2023 reflected a BIMs score of 0 indicating the resident was not able to complete the BIMs. The staff assessment for mental status indicated memory problems. Record review of Resident #26's Care Plan dated 02/27/2020, reflected, Focus: [Resident #26] has Suprapubic Catheter 18fr 1 Dec balloon R/T Dx Obstructive Reflux Uropathy and is change PRN, on Tamsulosin capsule. Goal: I will be/remain free from catheter-related trauma through review date. Intervention: Change Catheter and drainage bag based on clinical indications such as infection, obstruction, when the integrity of the closed system is compromised, etc. An observation on 02/06/2024 at 12:05 PM revealed Resident # 26's catheter bag dragging on the floor while he was at one of the dining room tables. Resident #26 was being assisted to eat by CNA D. There were two other residents at the table with Resident #26 and residents at all other tables in the dining room. In an interview on 02/06/2024 at 12:05 PM, CNA D stated Resident #26 needed assistance to eat because he was blind. He said he did not realize the catheter bag was dragging on the floor under Resident #26's wheelchair. He stated the bag should be off the ground at all times and when on the ground or dragging, it could tear causing an infection control concern. In an interview on 02/06/2024 at 12:05 PM, Resident #26 said he was blind and did not know his catheter bag was dragging on the floor. He said he preferred it to be off the ground under his wheelchair, so it did not get caught on anything. He said he did not recall who hung the bag on his wheelchair. 675870 Page 22 of 23 675870 02/08/2024 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 - Few In an interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services said catheter bags should be contained and off the floor to minimize the possibility of spillage and spread of infection. She said staff were in serviced on infection control practices but could not recall when the last in-service was. She said it was all staff's responsibility to watch for these issues to ensure infection control. In an interview on 02/07/2024 at 2:45 PM, the Administrator stated the catheter bags should not be touching the floor at any time. She said they could get caught on something and spill body fluid in the facility posing an infection control issue. She said nursing staff were responsible to ensure infection control policies were followed to minimize any risk of the spread of infection. In an interview on 02/08/2024 at 11:16 AM, CNA E stated she worked on Resident #26's Hall. She stated she tried to ensure catheter bags were not on the floor. She said if they touched the floor they could get torn and spill urine on the floor causing an infection control problem. She said all staff were responsible to ensure infection control policies were followed. She said she had received training in infection control by could not recall when the last time was. In an interview on 02/08/2024 at 11:16 AM, RN F said he worked on the hall where Resident #26 resided. He stated catheter bags should not be on the floor or touching the floor because they could rip. He stated he rounded often and expected CNAs to watch for this throughout their shift. He said it was infection control policy to ensure the bags did not touch the floor. Record review of the facility's policy titles, Infection Control Guidelines for All Nursing Procedures, revised, November 2023, revealed, Purpose: To provide guidelines for general infection control while caring for residents. General Guidelines: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes . In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted 675870 Page 23 of 23