Health inspection·March 24, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food orally from 1 of 1 facility kitchen in that: 1)Food was not stored properly in the refrigerator and in the pantry. 2)Food were past the manufacturer's Use by dates and were stored with current foods (juice concentrates) These failures could place residents at risk of foodborne illness. The findings included: The following kitchen observations were made beginning on 3/22/22 at 9:22 AM and concluding at 10:10 AM: In the pantry, one 7lb can of pork and beans, one 7lb can of grape jelly and one 7lb can of dice pears were stored on the floor. One box of parboiled rice was wide open and not sealed. On a food storage shelf by the refrigerator, there were six large containers of Prune Juice concentrate that were labeled Used by 3/8/22. In the walk-in refrigerator, one container of Homestyle Coleslaw was not sealed properly and was open to air. One container labeled 10 Beef Patties was undated in the refrigerator. Interview and observation on 3/22/22 at 9:50 AM with the Dietary Manager, she was asked who was responsible for monitoring to ensure that these foods were within the manufacturer's Use by date. Dietary Manager stated all dietary staff was responsible for expired items in the kitchen. Interview on 3/23/22 at 2:17 PM with Dietary Manager stated, she normally checked for food items on the floor, expired items, undated items, and opened food containers in the morning. Dietary Manager stated the cooks should also be checking for these items. Dietary Manager stated she last did a complete kitchen check on 03/20/22 and everything was in order. Dietary Manager stated she didn't have time to check the kitchen yesterday morning and was surprised to see cans on the floor and opened food containers. Dietary Manager stated staff get trained at least monthly regarding proper food storage. Dietary Manager stated she did not know how these food items were missed and she believed it was an accident. Dietary Manager stated the residents were at risk for getting sick due to the improper Page 1 of 7 675874 675874 03/24/2022 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0812 storage of food items. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure titled, Food Storage, dated 2018 reflected the following: Residents Affected - Some Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all foods will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry Storage Rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. h. Store all items at least 6 above the floor . 2. Refrigerators d. Date, label, and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage 675874 Page 2 of 7 675874 03/24/2022 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

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** Residents Affected - Few 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 3( #52, #78, and #79) out of 31 residents. 1. RN B failed to perform hand hygiene prior to gathering wound care supplies. 2. Wound care nurse RN B failed to perform hand hygiene during wound care. 3. LVN A failed to clean the medication cart, nurses' station, or the bottom of the caddy to prevent the possibility of infection from spreading. These failures could result in the spread of infections to the residents in the facility. The findings included: Record review of Resident #79's face sheet revealed a [AGE] year-old male resident with an admission date of 05/24/2016 and a readmission date 01/10/2022 with the following diagnosis: high blood pressure, vitamin D deficiency, frequent heartburn, type 2 diabetes with high blood sugar, dementia, too many lipids (fats) in the blood, anxiety disorder, Diverticulitis (inflammation or infection in one or more small ouches in the digestive tract), Mononeuropathy (damage to a nerve outside the brain and spinal cord), vitamin B12 deficiency anemia, difficulty walking, muscle weakness, major depressive disorder, post-traumatic stress disorder, Alzheimer's disease, history of thrombosis (blood clot) . Record review of Resident #79's quarterly MDS dated [DATE] revealed Resident #79's BIMS (Brief Interview for Mental Status) of 06, which indicated very severe impairment. Record review of Resident #52 face sheet revealed a [AGE] year old male resident with an admission date of 08/19/2020 with the following diagnosis: benign prostatic hyperplasia (age-related prostate gland enlargement that can cause urination difficulty), hyperlipidemia (too many lipids (fats) in the blood), neuromuscular dysfunction of bladder (lacks bladder control due to brain or spinal nerve problems), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath). Record review of Resident #52's annual MDS dated [DATE] under section C revealed Resident #52's BIMS (Brief Interview for Mental Status) of 9, which indicated the resident was moderately impaired. Resident #52 was at risk for pressure ulcers and developing pressure ulcers and it indicated that the resident does have a stage 2 pressure ulcer. The MDS indicated that pressure ulcer/injury care of 675874 Page 3 of 7 675874 03/24/2022 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0880 application of non-surgical dressings and application of ointments/medications. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #52's physician orders dated 03/23/2022 and start date of 03/23/2022 indicated: Stage II PI to Coccyx; Cleans with NS or wound cleanser, pat dry, collagen and foam dressing and prn until healed as needed for Wound Healing. Residents Affected - Few Record review of Resident #52's care plan indicated in part: (1.) My skin is fragile, and I am at risk for skin injury--new or worsening skin condition. Stage II Coccyx. Date Initiated: 02/02/2022 . I will have intact skin, free of redness, blisters, or discoloration by/through review date . Date Initiated: 08/20/2020. Keep clean & dry and apply skin barrier cream as indicated. Record review of Resident #78's face sheet revealed a [AGE] year old male resident with an admission date of 05/23/2017 and a previous admission date of 07/23/2015 with the following diagnosis: non-Hodgkin lymphoma lymph nodes of multiple sites (cancer that starts in the lymphatic system), congestive heart failure, hypertension (high blood pressure), alcohol dependence, hyperlipidemia (too many lipids (fats) in the blood). Record review of Resident #78's annual MDS dated [DATE], under section C- Cognitive Patterns indicated that Resident #78 had a BIMs (Brief Interview for Mental Status) of 15, which indicates intact cognition. It also indicated that Resident #78 is at risk for developing pressure ulcers/injuries. Record review of Resident #78's physician orders dated on 03/12/2022 and start date of 03/13/2022 indicated: Cleanse wound to left forehead with NS/wound cleanser, pat dry and LOTA until healed. If area is bleeding, cover with non-adherent dressing until controlled. every day shift for Wound Healing. Record review of Resident #78's physician orders dated on 03/12/2022 and start date of 03/13/2022 indicated: Cleanse wound to left [NAME] with NS/Wound Cleanser, pat dry, LOTA until healed. If area is bleeding, cover with non-adherent dressing until healed. every day shift for Wound Healing. Observation and interview on 03/23/2022 at 07:34 AM, LVN A conducted a glucose check on Resident #79. LVN A took a blue carrying caddy into the Resident's room with necessary glucose materials and set it on the Resident's table where his belongings were located. LVN A did not clean the table or provide a barrier before placing the caddy on the table. LVN A conducted the glucose check then proceeded to leave the room with the caddy to acquire insulin for the Resident#79. LVN A took the caddy and set it on another medication cart, then took the same caddy and put it on the nurses' station. LVN A then came back to Resident #79's room to administer insulin and set the same caddy back on top of the Resident's table. LVN A did not clean the medication cart, nurses' station, or the bottom of the caddy. LVN A stated, she did not clean the caddy and that leaves the potential of passing an infection if not cleaned properly. During an interview with the DON on 03/23/2022 at 9:11 AM,. the DON stated that if a carrying caddy was used, there should be a barrier between the caddy and the resident's table, or the caddy needs to be cleaned upon leaving the room to prevent the spread of infection. During an observation and interview of wound care of Resident #52's pressure ulcer to center coccyx, stage 2, with RN B on 03/23/22 at 9:59 am. RN B conducted wound care on Resident #52 back lower buttock area. RN B gathered supplies to conduct wound care on Resident #52 and did not wash her hands or use hand sanitizer prior to gathering supplies. RN B cleaned the bedside table with a 675874 Page 4 of 7 675874 03/24/2022 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disinfectant wipe, placed a barrier on the bedside table and then placed her supplies on the barrier of the bedside table. RN B then washed her hands, put on clean gloves. RN B removed Resident #52's brief and turned Resident #52 to the right side. RN B stopped and laid Resident #52 on his back and then raised Resident#52's bed. RN B stated that the bed was too low. RN B removed old gloves and replaced with a new pair of gloves. RN B raised bed and then turned Resident #52 to the right side to remove the old foam bandage. Observed that old bandage was dated 3/22/22 and initialed. RN B did not use hand sanitizer or wash hands prior to replacing gloves from removing the old bandage and cleaning the wound. RN B used the 4 X 4 gauze that was soaked with wound wash to begin cleaning the wound. RN B stated that she did not remember seeing an order to dress the wound. RN B stopped the wound care and placed a clean brief on Resident #52 without dressing the wound. RN B removed old gloves and RN B washed her hands after cleaning the wound. RN B immediately reached out to the Nurse Practitioner using the computer for orders to dress the wound. RN B stated that it could take a couple of hours to get orders placed to be able to dress the wound. During an observation of wound care of Resident #78 wound to left [NAME] and left side forehead, with RN B on 03/23/22 at 10:43 am. RN B conducted wound care on Resident #78 left side forehead. RN B gathered supplies to conduct wound care on Resident #78 and did not wash her hands or use hand sanitizer prior to gathering supplies to conduct wound care. RN B wiped off the bedside table with a disinfectant wipe and placed wax paper on the bedside table for a barrier. RN B placed all supplies on the barrier on the bedside table. RN B washed her hands and placed on clean gloves. RN B used 4 x 4 gauze that was soaked with wound wash to clean Resident #78 wound on left side of forehead. RN B used dry gauze to pat dry the wound. RN B left the wound open to air as instructed by orders. RN B removed dirty gloves and disposed in the designated trash. RN B washed hands and removed trash from Resident #78 room. Interview with RN B (wound care nurse) on 03/23/2022 at 11:12 am. RN B stated that today was her first day in doing the wound care position and she was nervous. RN B stated that she does realize that she should have washed her hands prior to gathering her supplies and during the wound care procedure but was not thinking about it. RN B stated that when she had to stop the wound care because of the bed and then because of the orders threw off the procedure and stated she lost track. She stated that she has been trained in hand washing throughout school and often in the facility. RN B stated that the negative potential outcome for the resident was the spread of infection to the residents. Interview with (Intern DON) on 03/24/2022 8:10 am DON stated that RN B should have known better because she used to be a DON in another facility, and she should have known to wash her hands. DON stated that she does understand that the RN B has not been in the position of wound care nurse for very long, but she should already know to wash her hands and that she will do an in-service with her. DON stated that RN B has been trained through school and the facility do skills checks for hand washing monthly and the staff have in-services as well. DON stated that it was the responsibility of herself and the administrator to make sure that the skills checks are completed and up to date. DON stated that the potential negative outcome for the resident's would be that by not washing hands it could possibly cause infection and spread from resident to resident. Interview with Administrator on 03/24/2022 8:42 am, Administrator stated that she does expect that a nurse should know to wash her hands prior to gathering supplies and treating wounds. Administrator stated that the facility has been in the middle of hiring new people to fill the positions that have been empty, and the wound care nurse position is one of those positions. Administrator states that it was nursing 101 to automatically know to wash your hands. Administrator stated that the staff members were trained and do have skills checks and matter of fact the facility just conducted a skill 675874 Page 5 of 7 675874 03/24/2022 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few check on 03/ 10/2022 for hand washing. Administrator stated that the facility provides reliase which is a computer-based training provided monthly and the facility also provides monthly revolving schedule for different kinds of checks such as handwashing. Administrator stated that it was the responsibility of her and the DON but mainly the DON to make sure that these trainings were completed and up to date. Administrator stated that the facility also makes sure to conduct a skill check upon hire to make sure that the staff member does know how to do what they are asked. Administrator stated that the potential negative outcome for the residents would be the transfer of infection. Administrator stated that if she had been treating and infected wound, she could have transferred that infection to another resident. Record Review of the facility provided policy titled; Infection Control dated July 2014 revealed. 2) C. Establish guidelines for implementing Isolation precautions, including Standard and Transmission-Based Precautions. 4) All personnel will be trained on out infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Record Review of the facility provided policy titled; Infection Control & Prevention no date labeled, revealed: Skill: Hand-Hygiene: Purpose: To prevent cross contamination and the spread of infection. Guidelines and Precautions: 1. Handwashing is the single most important method in the prevention and control of infection. 2. Handwashing should be done at the following times: B). Before and after caring for each resident. C). Before applying gloves and after removing gloves. E). After contact with blood, body fluids, and contaminated items. F). Whenever hands are obviously soiled. Record Review of the facility skills checks provided titled; SVH COVID Contact & Documentation Tracker no date labeled revealed: 1. 675874 Page 6 of 7 675874 03/24/2022 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0880 On 11/23/2021-Hand Hygiene skill performed. Level of Harm - Minimal harm or potential for actual harm 2. On 03/10/2022- Hand Hygiene skill performed. Residents Affected - Few 675874 Page 7 of 7