Health inspection·April 11, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 of 4 residents (Resident #39) reviewed for care plans. The facility failed to update Resident #39's care plan to reflect current needs for heel protectors to be worn at all times. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities was severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person Hoyer lift for transfers. Record review of Resident #39's Physician Order for the month of 04/2024 reflected a physician order dated 04/10/2024 wear heel protectors at all times; offload right heel when in bed. Page 1 of 14 675923 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview and record review on 04/10/2024, LVN C stated Resident #39 had an official physician order in the electronic medical record on 04/10/2024. She viewed Resident #39's physician order and care plan during the interview. She stated on the care plan, it reflected Resident #39 was to offload his heels when in bed. LVN C also stated the care plan date was 03/14/2024 and it was the most current care plan. She stated the care plan was completed prior to the new physician order dated 04/10/2024 for Resident # 39's heel protectors to be used at all times. She stated Resident #39's care plan had an intervention of offloading heels. However, this was different than wearing heel protectors. LVN C stated the interventions for the staff to follow required to be very specific. LVN C stated anytime there was a change in a resident care or any new order for any device the residents' care plan was expected to be updated. She reviewed Resident #39's care plan during the interview and stated the care plan was not updated to reflect the new physician order for the resident to have heel protectors on his feet. She stated care plan said to offload his heels but the care plan was written prior to him developing the red area on his right heel and offloading was not the same as wearing heel protector. She stated someone would probably update the care plan to reflect he needed heel protectors. She stated someone in the nurse administration department would review Resident #39's care plan and add the heel protectors to the care plan. LVN C also stated it was the MDS Nurse, the DON or the ADON revised the care plan. In an interview and /record review on 04/11/2024 at 9:30 AM, CNA F stated there was a form in Resident #39's room explaining the care he required. She stated the CNAs referred to the form for any changes in Resident #39's care. CNA F stated LVN E gave her report that morning about Resident #39 and to place heel protectors on him at all times. She stated if she saw offloading heels at all times documented, she would not know exactly what it meant. She stated she would need further guidance from the nurse to ensure she knew what to do if she saw the residents' heels needed to be offloaded. CNA F stated if she saw heel protectors on any of Resident #39's forms, she would know exactly what to do and she would place heel protectors on his feet. In an interview and record review on 04/11/2024 at 8:40 AM, the Director of Nurses stated as she was reviewing the Resident #39's care plan during the interview the interventions was not revised to reflect he was to wear heel protectors at all times. She stated the last care plan was revised on 3/14/2024 and the new physician order for heel protectors was dated 04/10/2024. She stated, in the perfect world the care plan would be revised. She also stated the care plan was the record the staff referred to when developing person center care for each resident. She stated offloading heels was on the care plan and that was when staff would use pillows under residents' feet. She stated again in a perfect world the care plan would be revised. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated the care plan for Resident #39 did not reflect specific heel protectors on the care plan. He stated the care plan had offloading and he believed offloading and heel protectors was the same thing but he was not a nurse. He also stated he was not going to discuss the potential negative outcome of a resident not wearing heel protectors because he was not a nurse. Record review of the facility's policy on Goals and Objectives, Care Plans dated 2009 reflected objectives were entered on the resident's care plan so that all disciplines have access to such information and were able to report whether or not the desired outcome were being achieved. Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 675923 Page 2 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

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 unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 40 and Resident # 63) reviewed for quality of life. Residents Affected - Few The facility failed to ensure Resident #40 and Resident #63's nails were cleaned. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 40 Face Sheet dated 04/11/2024 reflected Resident #40 was admitted on [DATE] with diagnosis of muscle weakness (lack of strength in muscles), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and age-related osteoporosis without current pathological fracture (reduce bone mass). Record review of Resident #40's Quarterly MDS Assessment, dated 02/26/2024, reflected resident was rarely/never understood. The staff completed Resident #40's cognitive status. Resident #40 was assessed to have poor short- and long-term memory recall. She was also assessed to have poor decision-making ability. Resident #40 was dependent on staff for all ADLS including personal hygiene. Resident #40 did not reject care. Record review of Resident #40's Comprehensive Care Plan dated 01/18/2024 reflected Resident #40 had an ADL self-care deficit related to general weaknesses, and cognitive deficits. Intervention: Explain to Resident #40 all care being given to her. Observation and Interview on 04/09/2024 at 1:19 PM Resident #40 had a blackish/brownish hard substance underneath the nails on her fore finger and middle finger on her left hand and underneath the nails on her middle finger and ring finger on her right hand. Resident #40 was not interview able. Record review of Resident # 63's Face Sheet dated 04/11/2024 reflected Resident #63 was admitted to the facility on [DATE] with diagnosis of: down syndrome (a condition in which a person has an extra chromosome or an extra piece of a chromosome), dementia in other diseases classified elsewhere, unspecified severity (lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement), and delusional disorders ( unshakeable belief in something that is not true). Record review of Resident #63's Quarterly MDS dated [DATE] reflected Resident #63 rarely/ never understood others. Her cognitive assessment was completed by staff. She was assessed to have poor short- and long-term memory recall and her decision-making ability was severely impaired. Resident required assistance with all ADLs. Record review of Resident #63's Comprehensive Care Plan dated 03/07/2024 reflected Resident #63 had ADL self-care deficit related to cognitive deficits. Care plan reflected Resident #63's ADL needs will be met. 675923 Page 3 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and Interview on 04/09/2024 at 1:11 PM Resident #63's middle and forefinger nails on her right had had blackish/brownish hard substance underneath the nails. Resident #63 was not interview able. In an interview on 04/11/2024 at 9:15 AM, LVN E stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN E stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated the CNAs reported to nurses of any diabetic resident's nails to be cleaned. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the Cans usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN E stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. She stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #40 or Resident #63 refusing nail care. In an interview on 04/11/2024 at 9:30 AM, CNA F stated CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails could be cleaned or trimmed by nurses or CNAs as needed. CNA F stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA F stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a Resident may need to be assessed at the emergency room if they became severely ill. She stated she gave care to Resident #40 and Resident #63, and with her experience they did not refuse nail care. In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated it was the nurse's responsibility to trim/clean residents with a diagnosis of diabetes. She stated CNAs were expected to give nail care to other residents during showers or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. Director of Nurses stated if staff saw a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. In an interview on 04/11/2024 at 3:25 AM, the Administrator stated nail care was overseen by nurses and the CNAs assisted with nail care directed by the nurse. He stated the nurses were expected to keep the residents' nails trimmed, cleaned, and filed. He stated he was not a nurse and could not speculate what may happen to a resident if the resident ingested some type of bacteria. Record review of the facility's policy on Fingernails/Toenails, dated February 2018, reflected nail care included daily cleaning and regular trimming. Clean the nail bed and keep the nails trimmed, and to prevent infections. 675923 Page 4 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

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 that residents received care, consistent with professional standards of care to prevent development of pressure ulcers for one of three (Resident # 39) reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #39 received his physician ordered heel protectors at all times. This failure could place residents at risk for developing a pressure ulcer leading to pain, discomfort, and potential infections. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 -year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities were severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person mechanical lift for transfers. Record review of Resident #39's Physician Order for dated 04/10/2024 reflected for the resident to wear heel protectors at all times; offload right heel when in bed. Record review of Resident #39's skin assessment dated on 04/03/2024 reflected Resident #39 had pressure on his bilateral heels (no measurements on the skin assessments). Record review of Resident #39's Nurse Practitioners notes dated 04/11/2024 reflected Resident #39 was seen on 04/09/2024. Resident #39's chief complaint was reports of redness to bilateral heels. Right heel medial aspect with approximately 2.5 x .2.5 purplish slightly blanchable area to heel. Assessment/Plan: Pressure injury of heel- suspect pressure related. Add heel protector booties at all times. Offload Right heel when in bed. Pressure Ulcer of unspecified heel, unspecified stage. Signed by Nurse Practitioner. 675923 Page 5 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0686 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #39's skin assessment dated [DATE] reflected Resident #39 did not have any skin concerns. Record review of Resident #39's skin assessment dated [DATE] revealed Resident #39 did not have any skin concerns. Residents Affected - Few Record review of Resident #39's skin assessment dated on 03/30/2024 revealed Resident #39 did not have any skin concerns on his right heel. Record review of Resident #39's skin assessment dated on 04/03/2024 revealed Resident #39 had pressure (sore) on his bilateral heels. Record review of Resident #39's skin assessment dated on 04/11/2024 revealed Resident #39 had pressure (sore) on his right heel with measurement 1.7 cm x 1.3 cm. Observation on 04/10/2024 at 10:30 AM revealed Resident #39 was in the common tv area in his specialized wheelchair. Resident #39 was not wearing heel protectors. In an interview on 04/10/2024 at 10:45 AM, CNA D stated she received report from LVN C during report at the beginning of her shift on 04/10/2024 to ensure Resident #39 was wearing his heel protectors when out of bed and to ensure he had pillows underneath his heels when he was in bed. She stated when she assisted Resident #39 out of his room to the common tv area, she forgot to place the heel protectors on his feet. CNA D stated the heel protectors was available in Resident #39's room. She stated if he did not wear his heel protectors, the areas on right heel may develop into a wound. CNA D stated the heel protectors were used to prevent him having a pressure wound. In an interview/record review on 04/10/2024 at 11:05 AM, LVN C stated the Nurse Practitioner was at the facility on 04/09/2024 and checked Resident #39's heels. She stated a verbal order was given to her from the Nurse Practitioner to place heel protectors on Resident #39's heels to prevent pressure ulcer to his right heel. She stated she thought she documented about the order in the nurses notes or the physician orders. LVN C viewed the physician orders and the nurses note during the interview. She stated she did receive a verbal order to place heel protectors on Resident # 39's heels on 04/09/2024 but she did not document this order. LVN C stated the order was entered into the electronic medical record on 04/10/2024. She stated the staff had been offloading Resident #39's heels when he was in bed. She stated offloading heels and placing heel protectors on the heels were two different interventions. She stated offloading heels was an intervention of placing a pillow underneath the residents' feet. LVN C stated it had to be very specific when placing heel protectors on residents' feet to prevent skin breakdown. She stated he had been wearing heel protectors on 04/09/2024 due to the Nurse Practitioner gave her a verbal order to place the heel protectors on his feet. LVN C stated Resident #39 was expected to have heel protectors on when he was in the common area on 04/10/2024. She stated she gave report to the CNAs to place heel protectors on Resident #39 heels when he was out of bed and to offload his heels when he was in bed by using a pillow. In an interview/observation on 04/11/2024 at 9:15 AM, LVN E stated she worked with Agency and this was the first day she had worked at the facility in a few months. She stated Resident #39 was required to wear heel protectors related to a small new area on his right heel. LVN E also stated he was to wear heel protectors at all times. She stated the heel protectors was better for him than offloading his heels with a pillow. She stated the night nurse (she couldn't remember the nurse's name) gave her report on 04/11/2024 when she came to the nurse's desk at the beginning of her shift. LVN E 675923 Page 6 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the night nurse told her in report Resident #39 was offloading his heels on a pillow and now he had a new order to wear heel protectors. LVN E stated she discussed this information with the CNAs after she received her report from the nurse on night shift. LVN E stated Resident #36 did have heel protectors on his feet when she made rounds on 04/11/2024. LVN E stated Resident #39 was in his room and when entered Resident #39's room he was wearing heel protectors while he was in bed. LVN E stated the heel protectors were to be worn at all times in bed and out of bed. She stated the heel protectors was a different intervention than offloading heels on a pillow. In an interview on 04/11/2024 at 9:30 AM, CNA F stated she was informed Resident #39 was expected to wear heel protectors when out of bed, during the morning report when she began her shift on Resident #39. She stated she was informed Resident #36 was expected to wear heel protectors when in bed and out of bed. She stated this was a new order for this week. She stated prior to this week, the staff was placing pillows underneath his feet and he was not wearing heel protectors. In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated there was a new order on 04/10/2024 for Resident #39 to wear heel protectors. She stated if Resident #39 was sitting in the common area on 04/10/2024, he was expected to be wearing heel protectors. The Director of Nurses stated when a resident had a red area on heel the intervention of wearing heel protectors was prevent the area from developing into a wound/pressure ulcer. She stated the staff was expected to place heel protectors on Resident #39. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated if there was an order for Resident #39 to wear heel protectors, he expected the heel protectors to be on resident per physician order. He stated he could not respond to the question of what possibly may occur to the resident if he did not wear heel protectors. He stated he was not a nurse. Record review of the facility's policy on Support Surface Guidelines, dated 2011, reflected support surfaces were to promote comfort for all bed, chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. 675923 Page 7 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

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, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the food was safely stored in the freezer and the pantry. This failure could place residents at risk of being served food that could had been crossed-contaminated, frost bitten, and foodborne illness. Findings included: Dry pantry observation on 04/09/2024 at 8:55am revealed an undated plastic container of Fiber. Dry pantry observation on 04/09/2024 at 9:00am revealed an opened bag powered milk, exposed to open air, and not sealed. Refrigerator observation on 04/09/2024 at 8:59am revealed a box of mushrooms in the refrigerator, exposed to open air and not sealed. Kitchen observation on 04/09/2024 at 8:46am revealed a cell phone in a pink protective case sitting on the rolling cart next to the prep table , directly across from the kitchen entry doorway. Kitchen observation on 04/09/2024 at 8:51am revealed a cloudy, chunky, brown liquid substance in the drain receptacle of the ice machine nearest to the steam table. Kitchen observation on 04/09/2024 at 8:53am revealed a greasy substance, food crumbs and other unidentifiable particles on the bottom shelf of the prep table where the spices and bottled sauces were stored. Pantry observation on 4/09/2024 at 8:57am revealed two small containers of Chicken Flavored Base sitting on top of a large 5-gallon bucket of Ultra San sanitation product. Pantry observation on 04/09/2024 at 8:57am revealed individual sized yellow packets of artificial sweetener, a Styrofoam cup, and other unidentifiable debris on the floor in the dry storage pantry, between the defrost refrigerator and a stack of boxes. Kitchen observation on 04/09/2024 at 9:05am revealed debris and trash, multiple divided plates, bowls, bubble cups, drinking glasses and multiple disposable containers under steam table. Kitchen observation on 04/09/2024 at 9:05am revealed cloudy, greasy water that contained food particles such as an Asian dumpling, a green bean and a French fry in the three wells of the steam table. Kitchen observation on 04/10/2024 at 11:37am revealed a cell phone, a smart watch, keys and an unopened can of soda on the rolling blue cart beside steam table. On top of the cart contained plastic bags with bread and serving trays. 675923 Page 8 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Kitchen observation on 04/10/2024 at 11:38am revealed a cloudy, chunky liquid substance in the drain receptacle of the ice machine nearest to the steam table. Appears to be the same liquid that was present yesterday. Kitchen observation on 04/11/2024 at 9:06am revealed a cell phone, keys, key fob, and a facility name tag. There was a pan of food sitting on the rolling tray. Kitchen observation on 04/11/2024 at 9:06am revealed on opened energy drink sitting next to a loaf of bread on a rolling cart. Kitchen observation on 04/11/2024 at 10:27am revealed debris and trash, multiple divided plates, bowls, bubble cups, drinking glasses and multiple disposable containers under steam table. Kitchen observation on 04/11/2024 at 11:20am revealed two kitchen staff wearing earbuds and one cell phone was ringing in the kitchen. The location of the cell phone was not identified, and kitchen staff ignored the ringing. Kitchen observation on 04/11/2024 at 12:31pm revealed small pieces of breakfast bacon and egg particles on the steam table, while lunch was served. Interview on 04/11/2024 at 2:30pm with the DA revealed she was trained by the KS. She said the kitchen cleaning checklists should be updated every day and all kitchen staff were responsible for this task. She confirmed she has read the policy on Kitchen Sanitation. She said she felt like the kitchen was clean. She said personal items are kept on the wall in the hallway, between the kitchen and the dry storage. She said this is important for sanitation purposes. She said items in the refrigerator should be stored in the container with the lid on top. She said all kitchen staff are responsible for ensuring all food items are safely stored and have an open date, to prevent the potential for bugs and other debris getting into the food. She said not storing food items properly could get the resident's sick. Interview on 04/11/2024 at 2:40pm with the KS revealed she was trained by her last company. She said cleaning checklists should be completed daily and she was aware the cleaning checklists had not been updated since the State had entered the facility. She said whoever complete d the cleaning task is responsible for documenting on the cleaning checklist. She said she read the Kitchen Sanitation policy when she was hired by the facility. She said her expectation is for things to be cleaned when something was dirty. Regarding cleanliness, she said, Currently, the kitchen could be better. She said that staff's personal items should be kept in the hallway, or her the supervisor's office. She said it is important to keep the kitchen free of personal items to prevent cross contamination with the food area. She said, staff are not allowed to wear ear buds in the kitchen due to safety regulations . Regarding the ice machine by the steam table, she said, It does not drain well. Maintenance has looked at it and it is a gravity issue. It is a non-functional ice machine and must be manually loaded with ice. I put Bleach in it at night. She said the steam wells should have been cleaned every day, usually by the night shift. She said food items should be sealed and closed with an opened and discard by date. She said the cooks and aides on each shift are required to label and date their own items that they prepared. She said it is important for food to be sealed and stored properly because it guaranteess freshness and nothing breeds bacteria that could cause food poisoning, spread contagion, cross contamination, and food allergies. 675923 Page 9 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 04/11/2024 at 2:50pm with the DM revealed that she held a Food Kitchen Managers Certification, she is an RD, and had classes in food management and production while in school. She said all kitchen staff are required to complete the cleaning checklist after they complete that task. She said she read the policy on Kitchen Sanitation when she was hired. When asked if the kitchen cleanliness met her expectations, she replied, For daily production measures, yes. That is always our highest priority. We cover our basics, cleaning all food and kitchen prep areas thoroughly. One area of focus in which we could improve, would be getting on your knees, cleaning the floors, etc. She said personal items should be kept in the hallway, on the hooks or on the fridge. She said it is important to keep the kitchen prep and line free of personal items to reduce cross contamination, safety and the correct level of cleanliness and it is not acceptable for staff to wear earbuds in the kitchen. She said staff knows not to wear earbuds in the kitchen. Regarding the ice machine near the steam table, she said, One or two times a week we empty the container. It's not hooked up to drain. Regarding the steam table wells, she said, That's a less frequent task, the cooks check off on that, one to two times a week. Regarding proper storage of food items, she said, Raw meat should be on bottom, anything with dripping juices on bottom, fresh produce on top, everything sealed in original packaging, or sealed with saran wrap or in a Ziplock. That is the responsibility of whoever opened the item. She said proper storage is important to prevent cross contamination with other foods and prevent foodborne illness, compromised immune systems in this population, insects, and foodborne intoxication. Interview on 04/11/2024 at 3:10pm with the RD revealed that the cooks and aides were responsible for updating the cleaning checklists when they complete a task. She said she has read the policy on Kitchen Sanitation, and she thinks if it is dirty, it should be cleaned. She said the kitchen does not meet her expectation for cleanliness. She said staff should keep personal items in the hallway or the mangers office. She said it is important to keep personal items out of the kitchen to prevent cross contamination. She does not like to see kitchen staff wearing earbuds, but I do see them when they are doing certain chores, like washing dishes. She said the ice machine drain pan should be dumped and cleaned every day. She said staff should label, date, and store items properly to ensure freshness and make sure the oldest items are used first. Interview on 04/11/2024 at 3:50pm with the ADM revealed his concern was constant turnover of kitchen staff. He was aware the kitchen is not as clean as it should be. He said he believes feeding the residents is the highest priority and the kitchen prep areas are clean and sterile. He said, The kitchen staff have to prioritize their duties, and no one is going hungry or has become ill. Review of the facility's Sanitization Policy revised November 2022) revealed the following: Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas are kept clean, free of debris and protected from rodents and insects. 10. I0ce machines and storage containers are drained, cleaned, and sanitized per manufacturer's instructions. Review of the facility's Food Receiving and Storage policy revised November 2022 revealed the following: Policy Statement: Foods shall be received and stored in a manner that complies with food handling practices. 675923 Page 10 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0812 Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 9. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Residents Affected - Some 675923 Page 11 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by contract staff in the direct care of one of four residents (Resident # 80) reviewed for infection control in that: Residents Affected - Few 1. The facility failed to ensure the Hospice Nurse LVN B sanitized or wash her hands after touching contaminated items while feeding of Resident #80. 2. The facility failed to ensure the Hospice Nurse did not touch Resident #80 tip of straw and side of Resident #80's mouth. These failures could place residents at risk of cross contamination which could result in physical illness. Findings include: Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (parts of the brain that control thought, memory, and language), diseases of lips (can make it difficult to eat, drink, or even smile. Cold sores cause by bacteria can be a common symptom), anxiety disorder (mental disorder that causes constant fear and worry), Down's syndrome (a condition in which a baby is born with an extra chromosome 21. The extra chromosome is associate with delays in the child's mental and physical development, as well as increased as an increased for health problems. Record review of Resident # 80's Significant Change MDS Assessment, dated 02/14/2024, reflected Resident #80 was never/ rarely understood and was not capable of completing the BIMS questions. Her cognitive patterns were assessed by the staff. Resident #80 had poor short- and long-term memory recall. Resident #80 required for the staff to do more than half the effort with feeding. Record review of Resident #80's Comprehensive Care Plan reflected Resident #80, dated 02/22/2024, reflected she had ADL self-care deficit related to decreased cognitive status. Intervention: Eating- assist resident to the dining room, set up meals and provide verbal cueing as needed. Resident was assessed to require hospice services related to Alzheimer's disease (parts of the brain that control thought, memory, and language). Intervention: will maintain communication between hospice and the caregivers of facility to meet the needs of the resident. Observation on 04/09/2024 at 12:05 PM- 12:10 PM, the Hospice nurse (LVN) B was feeding Resident #80 in the dining area on D hall. During feeding, Hospice LVN B placed the palm and fingers of her right hand at the top of her ponytail and went to the end of the ponytail. Her ponytail was approximately at her shoulders. After this, she touched the handles and back of Resident #80's wheelchair. She also touched Resident #80's clothing. Hospice LVN B did not sanitize or wash her hands and began to give Resident #80 her protein shake. When she picked up the protein shake, she placed the tip of her forefinger on her right hand on the tip of the straw and placed that portion into Resident #80's mouth. When she was holding the protein shake, the tip of her ring finger of her right hand touched Resident #80's left side of her mouth. The Hospice Nurse LVN B picked up the spoon from the bowl of chocolate pudding and touched the inside of the bowl with her middle and ring finger on her right hand and fed Resident #80. 675923 Page 12 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 04/09/2024 at 12:25 PM Hospice LVN B stated she sanitized her hands when she was in the hall walking toward the dining area. She stated she placed her bag on the floor and sanitized her hands again. Hospice LVN B stated when she began to feed Resident #80, she grabbed her ponytail with her right hand and run her fingers and palm of her hand through her hair. She also stated she touched Resident #80's wheelchair and clothing. She stated her hair, Resident #80's clothing and wheelchair would not be considered sanitized. She stated there was a possibility that bacteria were on Resident #80's clothing and wheelchair. She also stated her hair had hair products and possibly bacteria. Hospice LVN B stated she did not wash or sanitize her hands while feeding resident and after she touched these items (wheelchair, clothes, and hair). She stated she was to follow proper hygiene protocol when feeding or giving any type of care to a resident in the facility. She also stated there was a potential she may have cross contaminated the straw used for Resident #80 when she placed her fingers on the tip of the straw and when she placed fingers on her right hand by residents' mouth during feeding. Hospice LVN B stated there was a possibility of Resident #80 ingested bacteria from her fingers on her right hand the resident my become physically ill with a stomach issue and may have symptom of vomiting. She stated she had been in -serviced by the Hospice Agency she worked for on infection control and hand hygiene. She stated all nurses learned, in nursing school, proper hand hygiene when giving any type of care including feeding someone. She stated she made a mistake and she should have sanitized or washed her hands when feeding Resident #80 and she did not follow proper hand hygiene protocol. In an interview on 04/09/2024 at 1:20 PM, the Director of Nurses stated the hospice nurse was to follow proper hand hygiene when giving care to residents in the facility. She stated any nurse giving care whether it was a nurse employed at the facility or a nurse from another agency such as hospice giving care to a resident in this facility, were all to follow proper hand hygiene. She stated if the hospice nurse touched her own hair, touched Resident #81's wheelchair and clothes, she was expected to wash her hands prior to feeding Resident #80. She stated hand hygiene is basic nursing training. The Director of Nurses also stated any nurse learned proper hand hygiene protocol in nursing school and whenever given infection control in-service. She stated if a nurse touched anything considered contaminated was to wash or sanitize their hands immediately prior to given any care to a resident including feeding. She stated the hospice nurse did not practice good hand hygiene. In an interview on 04/10/2024 at 11:05 AM, LVN C stated any hospice staff who came into the facility to give care to any residents was expected to follow nursing protocol of hand hygiene. She stated she was in the dining room when Hospice Nurse LVN B was feeding Resident #80. She stated she was feeding another resident and was not watching Hospice Nurse LVN B. She stated if Hospice Nurse LVN B did not sanitize or wash her hands after touching her hair, someone else's clothing and parts of a wheelchair and continued to feed Resident #80, she did not follow nursing protocol of hand hygiene. She stated hand hygiene is what every nurse learns in nursing school and it is a part of the infection control protocol at every facility and agency. She also stated if Resident #80 ingested bacteria from Hospice LVN B's hands, Resident #80 possibly could become ill with any type of stomach issues. In an interview on 04/10/2024 at 1:04 PM, Director of Quality Assurance RN /BSN stated Hospice Nurse LVN B was required to follow the infection control protocol. She also stated hand hygiene for nurses was a standard protocol. She stated if a nurse had contaminated hands and gave any type of care to a resident , the nurse was expected to wash or sanitize their hands immediately before continuing care. She also stated this included feeding a resident. Director of Quality Assurance stated Hospice Nurse LVN B did not practice proper hand hygiene when feeding Resident #80 at the facility. She stated hand hygiene in-service was given to all nursing staff including Hospice Nurse 675923 Page 13 of 14 675923 04/11/2024 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN B. She also stated it was a possibility resident may become physically ill such as: the flu, respiratory issues, and a lot of different physical illnesses. Director of Quality Assurance RN/ BSN stated it deepened on the bacteria. In an interview on 04/11/2024 at 3:25 PM, the Administrator stated Hospice Nurse LVN B was expected to follow hand hygiene protocol when in the facility. He stated he was not a nurse and did not know all the specifics of what possibility could happen to Resident #80. He also stated hand hygiene protocol was expected to be known to all nurses who went to nursing school. Record review of the facility's policy on Hospice Program, dated 07/2017, reflected the facility staff (clinical nurse manager) provided orientation on the policies and procedures of the facility. Record review of the facility's Policy on Hand Hygiene in the Dining Room, not dated, reflected It is the policy of [FACILITY] to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting resident with eating. hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently. 675923 Page 14 of 14