Health inspection·February 24, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, clean, and homelike environment for 2 of 4 shower rooms (200 hall and 400 hall) reviewed for environment. 1. The facility failed to ensure shower room in 200 and 400 hall was free from black mold. 2. Resident #55 and Resident #76 voiced concerns with dirty shower rooms. This failure could place residents at risk for infection and a diminished clean, homelike environment. Findings included: 1.Observation on 2/22/23 beginning at 6:15 PM revealed 200 hall and 400 hall shower rooms had black debris mold along the edges of the shower area. Observation and interview on 2/22/23 at 6:29 PM the DON stated the black debris on the 200 hall shower room floor was black mold . The DON stated the Administration has known about the black mold since back in December of 2022. The DON stated all the residents in the 200 hall get showered in that shower room. The DON stated maintenance was responsible to clean the common areas. The DON stated there was a delay in maintenance disinfecting and cleaning due to the new Maintenance Director taking over not long ago. The DON stated she has voiced concerns to the Administration and even removed mold herself from the 200 hall shower room on the higher surfaces herself . The DON stated the mold could expose the residents at risk of infection. Observation and interview on 2/22/23 at 6:34 PM the DON stated the black debris on the 400 shower room floor was mold. 2.Record review of Resident #55 face sheet dated 2/24/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #55 history and physical dated 2/13/22 revealed diagnosis of dementia. Page 1 of 33 675927 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #55 Quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated moderate cognitive impairment. Interview on 2/23/22 at 10:29 AM revealed Resident #55 was in bed and stated she gets assistance from staff for her shower. Resident #55 stated she gets a bath at least 3-4 days a week. Resident #55 stated staff shower her in the shower room out in the hallway (200 hall) because she doesn't have a shower in her room. Resident #55 stated she has seen the shower room floor dirty several times and wished they would clean it more often. Record review of Resident #76 face sheet dated 2/24/23 revealed an [AGE] year-old female admitted on [DATE]. Record review of Resident #76 Quarterly MDS assessment dated [DATE] revealed a BIMS of 10, which indicated moderate cognitive impairment. Observation and interview on 2/23/23 at 10:41 AM Resident #76 stated she uses the shower room on the 400 hall. Resident #76 walked over to shower room in 400 hall and pointed at the black mold in the shower area. Resident #76 stated she wished the facility did better cleaning. Resident #76 stated the staff tend to run the water along the edges but the black debris does not come off and fears that it just spreads in the area she stands while she showers. Record review of Centers for Disease Control and Prevention: Mold last reviewed November 14, 2022 revealed Mold can cause many health effects. For some people, mold can cause a stuffy nose, sore throat, coughing or wheezing, burning eyes, or skin rash. People with asthma, immune compromised people and people with chronic lung disease may get infections in their lungs from mold. Record review of Publications / SHIB 03-10-10 A Brief Guide to Mold in the Workplace last updated on 11/08/13 revealed Introduction: Concern about indoor exposure to mold has increased along with public awareness that exposure to mold can cause a variety of health effects and symptoms, including allergic reactions. Mold Basics: Indoors, mold growth should be avoided. Problems may arise when mold starts eating away at materials, affecting the look, smell, and possibly, with the respect to wood-framed buildings, affecting the structural integrity of the buildings. Molds can grow on virtually any substance, as long as moisture or water, oxygen, and an organic source are present. Health Effects: The onset of allergic reactions to mold can be either immediate or delayed. Allergic responses include hay fever-type symptoms such as runny nose and red eyes. Molds may cause localized skin or mucosal infections but, in general, do not cause systemic infections in humans, except for persons with impaired immunity, AIDS, uncontrolled diabetes, or those taking immune suppressive drugs. Molds can also cause asthma attacks in some individuals who are allergic to mold. In addition, exposure to mold can irritate the eyes, skin, nose and throat in certain individuals. Symptoms other than allergic and irritant types are not commonly reported as a result of inhaling mold in the indoor environment. Prevention: Moisture control is the key to mold control. When water leaks or spills occur indoors - act promptly. Any initial water infiltration should be stopped and cleaned promptly. A prompt response (within 24-48 hours) and thorough clean-up, drying, and/or removal of water-damaged materials will prevent or limit mold growth. Record review of Quality of Life: Homelike Environment policy dated May 2017 revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These 675927 Page 2 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0584 characteristics include: A. clean, sanitary and orderly environment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675927 Page 3 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation; which included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat residents medical symptoms for 5 of 19 residents (Resident #50, Resident #71, Resident #42, Resident #180, Resident #62) reviewed for abuse. Residents Affected - Some A. 5 residents (Resident #50, Resident #71, Resident #42, Resident #180, Resident #62) were residing in the secure memory unit without physician orders and medical symptoms. These failures could place residents at risk of being separated against their will, without orders or the representatives consent. Findings include: Record review of Resident #50 face sheet dated 2/23/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #50 history and physical dated 1/13/23 revealed diagnoses of dementia with mild behavior disturbance. Record review of Resident #50 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #50 Memory Care Unit: admission Screening for Placement was not completed. Record review of Resident #50 care plan dated 2/21/23 revealed Resident is an elopement risk/wanderer and is at risk for possible injury related to impaired safety awareness and diagnosis of dementia and resides in memory lock down unit due to elopement risk. Record review of Resident #71 face sheet dated 2/23/23 revealed a [AGE] year-old female who was admitted to facility on 5/18/22. Record review of Resident #71 history and physical dated 5/25/22 revealed diagnoses of depression and dementia. Record review of Resident #71 active physician orders for February 2023 revealed no orders to be placed on secured memory unit . Record review of Resident #71 elopement assessment dated [DATE] revealed score of 5, which indicated medium risk. Record review of Resident #71 Memory Care Unit: admission Screening for Placement was not completed. 675927 Page 4 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #42 face sheet dated 2/23/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #42 history and physical dated 5/6/22 revealed a diagnosis of dementia. Record review of Resident #42 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #42 elopement assessment dated [DATE] revealed a score of 11, which indicated high risk. Record review of Resident #42 Memory Care Unit: admission Screening for placement dated 5/13/22 revealed section A. admission review the following were checked off: A. Resident has Alzheimer's or related dementia diagnosis. B. Resident habitually wanders or would wander out of the building, and would not be able to find their way back. F. Resident is able to ambulate independently. If no, please explain below in special concern/needs section below. G. Resident is able to benefit from a structured environment with specialized activities. Section C, admission decision revealed Resident meets the criteria for the Memory Care Unit. Was checked off. Record review of Resident #42 Memory Care Unit: Continue stay assessment dated [DATE] revealed section A. Continued stay review had the following checked off: A. Resident habitually wanders or would wander out of the building, and would not be able to find their way back. B. Resident has significant behavior problem that seriously disrupts the rights of other residents. C. Resident is a serious danger to self or others. F. Resident continues to benefit from a structured environment with specialized activities. Section C. continued stay determination revealed Resident continues to meet the criteria for placement on the Memory Care Unit was checked off. Record review of Resident #180's face sheet dated 02/23/23 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She had a diagnosis of dementia, depression and anxiety. Record review of Resident #180 History and Physical was not provided by facility at time of exit. Record review of Resident #180 physician orders revealed there were no orders for placement in the locked unit. Record review of Resident #180 Memory Care Unit: admission Screening for Placement dated 02/06/23 revealed Section A. admission Review the following sections were checked off: A. Resident has Alzheimer's or related dementia diagnosis. B. Resident habitually wanders or would wander out of the building and would not be able to find their way back. F Resident is able to ambulate independently. G. Resident is able to benefit from a structured environment with specialized activities. Record review of Resident #180's medical record revealed there was no re-assessment for Memory Care Unit Placement done. Record review of Resident #180 admission elopement risk assessment on PCC dated 02/20/23 revealed Elopement risk score was high at a 11.0. Section A. Resident Evaluation factors was documented Poor decisions, Dementia, Anxiety, Depression. History of leaving the facility marked with a note new admit, facility where she came from, she took off wander guard and walked out of facility. 675927 Page 5 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0603 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #62's face sheet dated 02/23/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's, Dementia, Major Depressive disorder and psychotic disorder that would cause delusions. Record review of Resident #62 History and Physical was not provided by facility at time of exit. Residents Affected - Some Record review of Resident #62 physician orders revealed there was no order for placement in the locked unit. Record review of Resident #62 's Medical Record revealed there was no admission Screening for Placement or Re-assessment for Continued Stay. Record review of Resident #62 last elopement risk assessment on PCC dated 02/08/23 revealed Elopement risk score was medium at a 5.0. Section A. Resident Evaluation factors was documented Alzheimer's, Dementia, Depression, Mood Disorder,. History of leaving the facility was marked with a no. Interview and record review on 2/23/23 at 11:43 AM the DON stated residents are assessed for elopement risk upon admission and as needed if they attempt to leave the facility. The DON stated if a resident is exit seeking, wandering and score high on elopement risk assessment, they place the resident on a wander guard first. The DON stated once a resident is on a wander guard and still seen attempting to leave the facility and succeed then they evaluate for [NAME] secure unit placement. The DON stated elopement risk and memory care unit admission assessment are tools they use to determine if a resident meets the criteria. The DON stated if a resident comes with history of elopement from a previous facility they are automatically placed in the facility's secured unit. The DON stated once they have determined a resident meets criteria to be placed on the secured unit they are to obtain a physician order from MD for placement. The DON reviewed Memory Care Unit Education in-service and stated they use that as a policy and guide for placement guidelines. The DON stated that the in-service read a physician order is required to have a medical reason. The DON stated elopement and safety were not considered a medical reason. The DON stated all residents who were currently placed in memory care unit required to have a physician order. The DON stated with no physician order and the physician orders that read elopement and safety that were not considered a medical reason, the residents residing in secured unit were not properly placed. Interview and record review on 2/23/23 at 12:27 PM the DOC stated residents were assessed with elopement and memory unit admission assessments to determine if they meet criteria for placement. The DOC stated residents were placed in secured unit for safety concerns. The DOC stated residents who had wandering behaviors and history of elopement would first be provided with wander guard then if that didn't appear to help, they would be considered for secured unit placement. The DOC stated if residents meet criteria to be placed in secured unit, they would obtain physician order to be placed in secured unit. The DOC reviewed Memory Care Unit Education in-service and stated it was a tool they used as guide to follow assessments to determine placement in secured unit. The DOC stated elopement and memory care unit admission assessment and continued stay were completed upon admission, quarterly and as needed if there was a change in condition by floor nurses. The DOC stated elopement and safety were not considered a medical reason to be placed, they were considered behavior concerns. The DOC stated if residents did not have a physician order to be placed in secured unit they should not be residing in secured unit. The DOC stated by orders not indicating a medical reason and not having any orders and residents residing in the secured unit was considered improper placement . The DOC reviewed Resident Rights policy and stated it could be considered involuntary seclusion. The DOC stated there were no consents obtained from family members. 675927 Page 6 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 2/23/23 at 1:23 PM the MD stated residents were placed on secured units because they have tendencies to escape and required a more controlled environment. The MD stated nurses and nursing administration conducted the elopement assessments and trusted their judgement. The MD stated when facility had a resident that met the criteria to be placed, they would call her and review the case and then come to a decision of placement. The MD stated after it was determined that a resident met criteria for secured unit placement, she would give a verbal order for the resident to be placed in secured unit. The MD stated she did not know if elopement and safety were considered a medical reason but that was what she and the facility were using. The MD stated if residents did not have a physician order to be placed in the secured unit, they should not be residing in the secured unit. Record review of Risk Management: Signaling Device policy dated 04/2020 revealed At times, the community admits and retains residents that are confused and have the tendency to wander about the community. If the community is equipped with a secured unit, these residents will normally be secured on this unit. The community must ensure the residents safety while utilizing the least restrictive means available. To meet this need, the community will obtain information pre-admission or admission conferences with the resident's and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. Record review of Memory Care Unit Education, not dated, revealed Evaluation of memory care units: 1. Residents are assessed upon admission or with changes in condition by the IDT using the Memory Care Unit admission Screening form in order to determine the need for memory unit placement. Residents will receive ongoing evaluations using the Memory Care Unit Continued Stay Review quarterly, annually, and with significant changes in condition to determine continued need for placement. 2. Residents will have physicians order stating the medical reason for secured unit placement. Record review of Resident Rights policy dated 12/2016 revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the residents' medical symptoms. Record review of Abuse policy dated 1/27/2020 revealed The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/ Confinement, and or Misappropriation of Property. The facility will adhere to policies and procedures and will follow the guidelines in the written policy and procedure. Residents will not be subjected to abuse, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents family members or legal guardians, care taker, friends, or other individuals. This includes physical, verbal, sexual, physical/ chemical resyrtaint. 675927 Page 7 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid including referring residents with newly evident or possible serious mental disorders for level II resident review upon a significant change in status assessment for one (Resident #10) of 6 resident reviewed for PASARR, in that: Resident #10 was admitted with a Level 1 PASARR indicating resident did not have a mental illness and or intellectual disability or related condition resulting in the facility failing to coordinate a Level II PASARR during resident screening. This failure could place residents at risk of not receiving specialized services that may assist them in attaining and or maintaining their highest practicable level of psychosocial functioning. Findings Include: Record review of Resident #10's Face Sheet indicates resident was admitted on [DATE] and readmitted on [DATE]. Record review of Resident #10's Annual MDS completed by MDS Nurse dated 02/08/2023 stated A1500 Preadmission Screening and Resident Review (PASARR) entered code was a 0. This indicated resident did not have a mental illness and or intellectual disability or related condition. A1510 - Level II Preadmission Screening and Resident Review was not conducted. Record review of Resident #10's medical diagnosis indicates resident had Unspecified Intellectual Disabilities on 02/22/2023 but was unable to determine if Resident #10 had a PASARR Level II completed upon admission or readmission. Record review of Resident #10's H&P (History and Physical) dated 02/25/2019 Annual Physical Examination under history has had a signature documenting mental retardation signed by the examining physician. Record review of Resident #10's view diagnosis dated 02/22/2023 indicates unspecified intellectual disabilities with a comment - mental retardation. Interview on 02/23/23 at 3:31 p.m., the DON stated the PASARR was to be completed during admission. The DON stated PASARR would be triggered if the resident had altered cognitive mental status. The DON stated MDS would conduct the PASARR which was then placed in a specified website the facility uses. The DON stated she was not 100 percent sure the PASARR was being done. The DON stated it was done for incoming or leaving residents. The DON stated her understanding of a PASARR would indicate if a resident would need referrals to see doctors and services to meet the needs of the resident. Interview on 02/23/2023 at 3:36 p.m., the MDS Nurse stated that a PASARR can be done with a change of condition and upon admission. The MDS Nurse stated the PASARR follow the online guidelines which were completed online. The MDS Nurse stated she would follow up on making sure the change of the conditions was inputted into the MDS. The MDS Nurse stated the residents receiving services would depend on the PASARR. The MDS Nurse stated that Resident #10's screening and assessments should have been 675927 Page 8 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0644 Level of Harm - Minimal harm or potential for actual harm looked at. The MDS Nurse stated she knew about the PASARR concern and did not mention it until it was time to do the audit. The MDS Nurse stated that Resident #10 was none verbal and because he was none verbal, he should have been evaluated. The MDS Nurse stated she did not believe there was a risk if the PASARR was being overlooked. The MDS Nurse stated she believed the residents would have benefited from the extra services the PASARR provided. Residents Affected - Few 675927 Page 9 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission for 1 of 8 residents (Resident #181) reviewed for baseline care plans. The facility failed to develop a baseline care plan within 48 hours of Resident #181 admission. This failure could place recently admitted residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #181 face sheet dated 2/23/23 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #181 history and physical dated 2/16/23 revealed a diagnoses of dementia, psychotic behavior, and generalized anxiety. Record review of Resident #181 physician order dated 2/14/23 revealed to be placed in secure unit due to risk for elopement. Record review of Resident #181 Memory Care Unit: admission Screening for placement dated 2/13/23 reveled section A. admission review the following were checked off: A. Resident has Alzheimer's or related dementia diagnosis. B. Resident habitually wanders or would wander out of the building, and would not be able to find their way back. F. Resident is able to ambulate independently. Section B: Special concerns or needs revealed a note Resident was eloping from previous facility and while out on pass at home with family. Section C: admission decision revealed Resident meets the criteria for the Memory Care Unit was checked off. Record review of Resident #181 baseline care plan revealed one had not been completed. Observation and interview on 2/21/22 during initial rounds Resident # 181 was in the memory care secured unit. She was wandering around the hallway saying she did not know why she was at the facility. Resident #181 appeared pleasantly confused. Interview on 2/23/22 at 11:45 AM the DON stated baseline care plan were created by the admitting nurses. The DON stated nurses received training regarding developing baseline care plans upon hire, annually and as needed. The DON stated nurses used physician orders and diagnosis to develop a baseline care plan. The DON stated by not creating a baseline care plan could affect monitoring and needs been being met . Record review of Resident Assessment: Baseline Care Plan policy dated 11/1/19 revealed A baseline care plan is required to be completed within 48 hours of admission. The baseline care plan must include: initial goals based on admission orders, physician orders, dietary orders, therapy services, 675927 Page 10 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0655 social services and passar. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675927 Page 11 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences in 1 resident (Resident #68) out of 8 reviewed for oxygen care in that: Residents Affected - Few -Nursing staff administered oxygen to Resident #68 without a physician's order. This deficient practice could cause a decline in health for residents receiving O2 without a physician order and who are not being monitored accurately. Findings included: Observations on 02/21/23 at 10:30 AM revealed Resident #68 was wearing nasal canula with 3 liters of oxygen. Review of Resident #68's face sheet dated 02/23/23 revealed an [AGE] year-old male with and admission date of 12/02/22. He had a diagnosis of Chronic Respiratory failure, meaning he had trouble breathing and required oxygen. Review of Progress notes dated 02/13/23 revealed Resident #68 supplemental o2 tank that remains in in his w/c was replaced by this nurse. Encouraged staff to ensure Resident #68 is on continuous o2 via N/C. Review of physician orders revealed there were no orders for oxygen or oxygen monitoring. Review of Resident #68's vital signs revealed his pulse oximetry had not been monitored or taken since 02/15/23. Review of comprehensive care plan dated 01/05/23 revealed ineffective breathing pattern related to COPD and CHF. (COPD is a lung disease that causes airflow limitation. CHF is a heart disease that causes shortness of breath due to overload of fluid). Goal was that Resident #68 would demonstrate effective breathing rate through interventions such as monitoring respiratory rate, and administer oxygen as ordered. Review of admission MDS assessment dated [DATE] revealed Resident #68 had a BIMS score of 5; indicating he was severely cognitively impaired. That meant he may have had impaired memory and difficulty with decisions. Section O revealed that Resident #68 had oxygen therapy. In an interview on 02/23/23 at 10:36 AM with DON, she said Resident #68's oxygenation had been monitored when they had COVID assessments, but it had not been assessed since. She said she did not know why the nurses were not monitoring his oxygen saturations. She said it was not good nursing practice to not monitor the oxygen saturations and said that if it was not documented then it was not done. She said the nurses knew how to monitor for pulse oximetry (oxygenation percentage in the blood), regardless of having an order. She stated Resident #68 did not have an order for oxygen and said it was the nurses' job to ensure oxygen order was in place if resident was receiving oxygen. 675927 Page 12 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0695 In a follow-up interview on 02/23/23 at 10:51 AM , DON reported there was no oxygen policy for the facility. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/24/23 at 10:12 AM with LVN F, she said was responsible for Resident #68 for that day. She said she knew Resident #68 had oxygen and said she had documented his pulse oxygenation on his chart. (At this time, she was asked to look at his vital signs and find his pulse oxygenation). She said, since he did not have an order to check his pulse oxygenation, it was not checked. She said it was important to monitor and check his oxygenation because he had COPD, and his oxygen could drop. She said she had been trained, but it had been a while. Residents Affected - Few 675927 Page 13 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interviews and record review, the facility failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 1 out of 4 (400 hall) narcotic count sheets and 1 out of 1 medication storage room reviewed for controlled medications in that: -Narcotic count sheet for 400 hall was missing staff signatures for 3 days (2/20, 2/21 and 2/22). -An unemptied open vial of Haldol medication was found inside the medication storage room and had not been wasted. This deficient practice could result in inaccurate count and destruction of controlled medications which could lead to a decline in health to residents receiving controlled medications. Findings included: Observations on 02/22/23 at 10:03 AM revealed Haldol medication vial was found in biohazard container uncovered without a lid or lock, inside the medication room. Haldol vial had about 0.25 ml of medication in it. Observations on 02/22/23 at 10:22 AM revealed the narcotic count sheet for the in 400 hall had nursing staff signatures missing for 2/20 night shift 2/21 day and night shift and 2/22 day shift. In an interview with the DON on 02/22/23 at 10:07 AM, she said the procedure for wasting medication was to have 2 nurses waste the medication in the medication room. Wasting medication meant discarding the remaining dose of medication. She said the vial should have not been in the Biohazard container because it was a controlled substance, and it should have been wasted. She said the nurses knew how to waste medication because she was responsible for training the nurses during on-hire orientation. In an interview with LVN E on 02/22/23 at 10:28 AM, she said she had counted the narcotics with the night shift nurse but had not signed the narcotic count sheet because she forgot to do so. She said she had been trained to complete the narcotic count check during on-hire training. She said the reason it should have been done was because there could be a discrepancy in the medications, and the staff could be short on medications for the residents. In an interview with LVN F on 02/24/23 at 10:20 AM, she said the nursing staff had to sign off on the narcotic sheet at the beginning and the end of the shift. She said that was done to ensure that the narcotic count was correct. In a follow-up interview with the DON on 02/24/23 at 10:28 AM, she said the nurse knew that part of their duties was to count the narcotics and sign off on the narcotic count sheet. She said it was important to do so in case some of the medications could be missing and the count could be off. She said the nurses had been trained on doing so before beginning their duties. Record review of staff training undated read in part .Narcotic sheets must be done after every shift and signed by nurses . 675927 Page 14 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of facility policy titled Controlled Substance Disposal dated 08-2020 read in part .When a dose of a controlled substance is removed from the container .it is destroyed in the presence of two licensed nursing personnel, and in accordance with facility policy and state regulations, and the disposal is documented on the accountability record . Record review of facility policy titled Storage of Controlled Substances dated 08-2020 read in part .At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and its documented . 675927 Page 15 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 drugs/biologicals reviewed for labeling in that: -Resident #10's tube feeding was unlabeled with feeding rate and time it was hung. This deficient practice could cause a decline in health in residents due to labeling errors/issues. Findings included: Review of Resident#10's face sheet dated 02/23/23 revealed a [AGE] year-old male with an admission date of 02/07/20. Review of Resident #10's History and Physical revealed he had a PEG tube and was receiving tube feedings. It also revealed he had dysphagia, which is difficulty swallowing. Review of physician orders dated 05/04/18 revealed Change feeding bag, tubing and syringe every 24 hours. Every night shift. It also showed his feeding formula to be Jevity 1.5 75 ml an hour. Review of Resident #10's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 3; meaning he was severely cognitively impaired. That meant he had difficulty with decision making and memory impairment. Section K of the MDS assessment revealed he had a feeding tube. Review of comprehensive care plan dated 03/02/21 revealed Resident #10 required PEG tube feeding related to aphasia (difficulty speaking). Goal was for Resident #10 to maintain adequate nutritional and hydration status through interventions such as providing full assistance with tube feeding. Observations on 02/21/23 at 10:28 AM revealed tube feeding formula was not labeled with time and date it was hung by the nurse. It was also missing the rate that the formula was running at per physician order. In an interview on 02/21/23 at 11:36 AM the DON stated the feeding tube formula had not been labeled correctly. She said it did not have the time or date it had been hung or the rate that the formula was running at. She said the feeding formulas were changed at midnight and changed by the night nurses. She said the nurses had been trained upon hire and annually. She said it was important to label the feeding correctly to ensure the proper feeding was obtained and given to the resident. In an interview on 02/22/23 at 10:55 AM with LVN E, she said the tube feeding formula had to be labeled correctly with date, time it was hung and the rate the formula was ordered for. She said the nurses had been trained to do so during orientation. She could not state a risk for the resident. Review of facility policy titled General Guidelines for Medication Administration dated 08-2020 read in part .Select the medication, check the label, container and compare against the MAR . 675927 Page 16 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services, in that: 1. Food products in dry storage, freezer, and in refrigerator were not correctly labeled, wrapped, or were expired. 2. Staff were not wearing hairnets properly or not at all while in the kitchen. 3. Sanitation Bucket Log (Is used to check the part per million of cleaning solution mixed with the water to make it is disinfecting) was not filled out every day. This these failures could affect residents by placing them at risk of food borne illness. Findings include: Observation on 02/21/2023 beginning at 9:38 a.m., with Dietary Manager in the dry storage revealed there was a 106 oz can of crushed pineapples on the roller shelf with a two-inch dent in the middle of the can. A 96 oz can of Apples slices in water was in on the roller shelve shelf which had on its left side squashed causing a fold around two to three inches in length. The upper and lower seals of the can were dented in. In the walk-in refrigerator sitting in the mid shelf was a red tray with four mugs/cups filled with a red substance. The first red cup to the left by itself had no covering or lid and was not dated. The two other cups lined up in a row had no proper seals or lids to properly cover the mugs/cups and the forth cup was in the back covered. In the walk-in was a clear sealed zip lock bag with celery inside of it with no label or date. In the walk-in on the bottom was a large metal sheet pan that was used for cheesecake that was not cover properly. On the left side of the cheesecake that was in the sheet; from top to bottom (2 feet length) and around two inches in width was not covered by the Saran Wrap. In the freezer there was a box big box of lasagna closed sideways around three inches off the floor sitting on a bag of ice jammed in between the racks and the freezer wall covered in ice. In the freezer underneath the big box of lasagna was a cup of ice cream on the icy floor next to two bags of ice. In the freezer on the bottom shelf was an undated/labeled clear sealed bag of sweet potato fries. In a white refrigerator (1 of 1 white Refrigerator) a clear plastic container possibly two inches in dept, had a cellophane wrap that was not providing a proper seal. In the white refrigerator in the door on the second shelf was a zip locked bag of lettuce the was looking slimy wet with the condensation on the zip lock and had parts that were dark green and brown. In the white refrigerator on the door on the top shelf was a sandwich that was left open squashed together with other sandwiches. It was left open in a clear see-through sandwich bag. On the shelf in the side prep area next to the front servicing area was containers. There was a large container of parsley that were not sealed. On the shelf in the side prep area next to the front servicing area 675927 Page 17 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was a metal container filled with thickener but it was not properly sealed. The Saran wrap was not grabbing then container and was hanging downwards on both sides. Observation and Record Review on 02/21/2023 at 11:04 a.m., facility Sanitation Bucket Log (Is used to check the part per million of cleaning solution mixed with the water to make it is disinfecting) for 2023 was not filled out for February 18th lunch and dinner and on the February 20th for breakfast and lunch and indicated the buckets are to be refilled after each meal and as needed. The above log is to be completed after each refill. Observation on 02/21/2023 at 12:20 p.m., Administrator walked into the kitchen with no hair net on heading towards the Dietary Manager's Office. Record review on 02/22/2023 at 3:54 p.m., of facility Sanitation Bucket Log for 2023 had the February 18th for lunch and dinner filled out and for the February 20th breakfast and lunch filled out. Interview on 02/21/2023 at 12:22 p.m., the Dietary Manager stated the facility policy stated that anyone coming into the kitchen needs to have a hair net on. The Dietary Manager stated the risk to the resident would be hair in the food. The Dietary Manager stated eating the hair could be gross, could cause choking, and get the resident's sick. The Dietary Manager stated all staff are trained on labeling, temps, and food preparation. The Dietary Manager stated the dented cans are separated from the good cans. The Dietary Manager stated dented cans could have particles inside of them and if used could get resident's sick. The Dietary Manger stated foods should be labeled and if they are not labeled staff will not know if the food is good to use. The Dietary Manager stated the under covered cheesecake that was on the bottom uncovered could have had particles or other unwanted foreign object falling into the cheesecake. The Dietary Manger stated these objects could potentially get the resident's sick. Interview on 02/23/2023 at 9:15 a.m., the Dietary Manager stated dietary staff are trained to document on logs and are shown how to fill them out. Dietary The Manager stated she checks daily and makes sure that the sanitation logs are filled out. The Dietary Manager stated she was out on the February 18th and did not oversee that the log was being filled out but instead Food Service Manager C was supposed to be checking it was being done. The Dietary Manager stated she did not have the answer as to who filled the sanitation log on 02/22/2023. The Dietary Manager stated the consequences of false reporting is a write up. The Dietary Manager stated they did not know if the sanitation fluid was actually sanitizing and don't know if that was correct. Dietary Manager stated the residents can get sick if they are not checking that the sanitation fluid making sure it was effectively sanitizing correctly. Interview on 02/23/2023 at 9:36 a.m., Food Service Manager C stated she makes sure when at work that the labels are done, temps, and sanitation logs are done. Food Service Manager (Picture of can dented was shown) stated the dented can should be in the area where they keep all the dented cans. Food Service Manager C stated the dented cans can be contaminated and have pieces of the metal inside that can go into the food. Food Service Manager C stated it can choke the resident and or cause botulism (food poisoning caused by a bacterium (botulinum) growing on improperly sterilized canned meats and other preserved foods). Food Service Manager C stated foods are supposed to be labeled and the facility ensures this by using the FIFO (First In First Out Method). Food Service Manager C stated dietary staff are to make sure they are not expired. Food Service Manager C stated the kitchen conducts in-services on labeling of foods. Food Service Manager C stated if foods are not labeled than then a resident can get sick form food borne illness if we are using expired foods. Food Service Manager 675927 Page 18 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some C stated even if they were busy, staff were trained to do dishes and the log and were supposed to fill out the log. Food Service Manager C stated the risk is that the sanitation was not being checked on properly to make sure it was sanitizing. Food Service Manager C stated residents can get sick. Food Service Manager C stated I cannot explain how the logs were filled out I was not here the last two days. Food Service Manager C stated she considered it to be false documentation. Food Service Manager C residents could get sick and become ill. Food Service Manager C stated she and or her supervisor when they are at the facility make sure they logs are being done. Food Service Manager C state when both supervisors are on shift, they try to make sure the dietary staff are doing their temps and logs correctly. Observation on 02/23/2023 at 9:57 a.m., Dietary Aide A was touching her exposed hair that was outside of the hair net with her hands. The hairnet was not covering up all of her exposed hair from the lower back left and right sides and in the front left and right sides where the sideburns come down. Interview on 02/23/23 09:57 a.m., with Dietary Aide A stated she received training from this facility and the food handlers training. Dietary Aid A stated working in the kitchen you need a hairnet and to cover all of your hair. Dietary Aide A stated the exposed hair could fall into the food of the residents and could contaminate the food causing the residents can get sick. Dietary Aide A stated no she would not be okay with people doing food for me that had exposed hair. Dietary Aide A stated if hair come came out in the food that she was eating she would not want to eat food. Dietary Aide A stated in labeling the dietary staff have to write the name, date, time, initials of staff. Dietary Aide A stated the purpose of labeling is to know how long the food has been there or when it was prepared. Dietary Aide A stated using the unlabeled food could not be good and or contaminated; it should be thrown away. Dietary Aide A stated it could have effects on residents if used because it could be spoiled and could get them sick. Dietary Aide A stated dented cans are not used because there could be pieces of metal inside of it. Dietary Aide A stated the risk to the residents could be food poisoning if used. Dietary Aide A stated the dietary staff have a place where all the dented cans go and later are discarded disregarded. Dietary Aide A stated the containers are to be closed well and covered well. Dietary Aide A (Picture was shown of the cheesecake) stated the cheesecake needed to be closed and sealed. Dietary Aide A stated the cheesecake being on the bottom shelf shelve, stuff could have fallen on it. Dietary Aide A stated the dietary staff have been trained on how to fill out the temps, sanitization logs and it was overseen by the Dietary Manager. Dietary Aide A (Picture was shown both sanitation logs from both different days) stated it is not appropriate to fill out the log on 02/22/2023 if dietary staff had not filled it out on 02/21/2023. Dietary Aide A stated dietary staff do keep notes or recording on the sanitation log anywhere else. Dietary Aide A stated dietary staff are not doing what they are supposed to because they filled it out the following day. Dietary Aide A stated filling out the sanitation log the next day was not right because no one not sure if the staff was changing the bucket out. Dietary Aide A stated she would consider it false documentation because the one before had it blank and this one had it filled out. Dietary Aide A stated the buckets not being properly checked could contaminate wherever you prep food, dihes, and utensils which could result in residents getting sick. Record review of Dietary Staff certification of completion Learn2Serve Food Handlers Training Course. Record review on of all Dietary Staff certification of completion ServSafe and Dietary Manger Food Production Manager Certification Examination dated 03/22/2022. Record review of facility in-service dated 04/12/2021 What to expect, Health Inspection Reading at 675927 Page 19 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0812 Level of Harm - Minimal harm or potential for actual harm all times. Page 2 talks about food storage: Food is kept at least 6 inches off the ground, Food is stored in a clean, dry location that is not exposed to contamination, containers are labeled with the food name and delivery date, Freezer and Refrigerator Maintenance, all food items are correctly labeled and dated. Sanitation: The sanitizer is mixed to the correct concentration, sanitizing buckets changed out as needed to temp. Employee Hygiene: Employees wear hairnets, and male employees cover facial hair. Residents Affected - Some Record review of facility policy dated 11/01/2019 - Food Service Uniforms stated it is the policy of that all employees wear a uniform that reflect the professional image of the Department of Food and Nutrition Services for Focused Post-Acute Care Partners. Procedure - Hair: All hair will be covered prior to entering the kitchen with a hairnet (men/women) or optional skull cap (men; women will wear hairnet and skull cap). Record review of facility policy dated 10/2017 - Food Receiving and Storage stated foods shall be received and stored in a manner that complies with safe food handling practices. Line 7. Dry foods that are stored in bins will be removed form original packaging, labeled and dated (use by dated). Line 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Line E. Other open containers must be dated and sealed or covered during storage. Record Review of facility policy dated 10/2017, Preventing Foodborne [NAME] - Employee Hygiene and Sanitary Practices stated Food and Nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Line 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and presenting foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Line 12. Hair nets or caps and/or beard restraints must be worn to keep hair form contacting exposed food, clean equipment, utensils and lines. 675927 Page 20 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 6 of 6 dumpster and 1 of 1 oil fryer container reviewed for food safety requirements. Residents Affected - Many 1. Garbage and refuse were observed on the ground near the dumpsters in the back of the facility. 2. 2 dumpsters were observed uncovered with garbage inside and one fry oil container was uncovered with used fry oil in it. This failure could affect residents by placing them at risk of illnesses, or be provided a unsafe, unsanitary and uncomfortable environment. Findings include: Observation on 02/21/2023 at 8:40 a.m., with Dietary Manager, six metal dumpsters and one metal oil (fryer) container were lined up in a row around 50 to 75 feet away from facility. The dumpster lids on most of all six dumpsters do not provide a proper seal as some are bent in various ways allowing access to the outside environment. One dumpster had its left side lid open and the other had its right-side lids open. The dumpsters with its left side lid open had a cardboard box sitting underneath its lower right side exposing 60 % of the cardboard box on the ground. The dumpster with the right-side lid open had a piece of dark grayish bag around a foot hanging in the air from its closed lid. Behind the dumpsters closest to the fryer container in between both dumpsters was a white plastic bag torn and caught on a plant with [NAME] that was approximately a foot away from the dumpsters. Next to the white plastic torn bag on the same plant but on a different branch was a bag string caught in the plant. Further down the behind the dumpsters was another plant with a white plastic bag caught in its [NAME]. Next to the fryer about a foot away was a brown cardboard on the ground. A foot away was another long piece of cardboard paper and a white plastic bag. Leaning to the side of the fryer container was cardboard sheet around 2 foot in diameter. The fryer lid was left opened. On the grill was a caked-on layer of grease. Next to the open lid on the right side was a two-to-three-foot two length by two-inch width piece of wood with white grease or fat particles dusted all over the wood and container. On the left side of the fryer lid was a dirty dusted butter knife. On the third dumpsters in the front was a piece of white paper lying on the ground half a foot diagonal to the dumpster. On the back side of the fryer was a nightstand, a broken pallet, three pieces of wood scattered, a green tea bottle on the ground floor, and four two feet by three-foot sheets of wood lying on the fryer. A white sugar packet and a red piece of possibly candy were on the ground. Dumpster furthers to the medical waste, behind the dumpster on the floor was a white spoon on the ground. Next to the medical waste was a white wooden stand with a blue sheet with hay on top of it. Two feet from it was a four-foot length by one foot width piece of wood lying on the ground. It was also observed that around the general area (grounds) was various kinds of trash scatted throughout the dumpster area grounds further away from the dumpsters. In the back entrance to the kitchen was a pile of cardboard boxes (8 varies sizes of boxes) emptied lying on the ground and on the side of the building. Interview on 02/21/2023 at 9:38 a.m., with Dietary Manager stated maintenance takes care of the 675927 Page 21 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many upkeep of the grounds and makes sure the grounds are clean. The Dietary Manager stated the dumpster lids are to be closed and not opened. The Dietary Manager stated they have in-serviced and [NAME]-serviced the dietary staff on keeping the dumpsters closed and area clean. The Dietary Manager stated that it is everyone's duty to ensure the dumpster lids are closed and making sure there is no trash around the dumpsters. The Dietary Manager stated the cardboards near the entrance of the kitchen have been on the floor since 02/20/2023 and have not been thrown due to not having staff. The Dietary Manager stated the dietary staff conducting the truck (on 02/21/2023) would throw away the cardboard boxes. Observation on 02/22/2023 at 5:13 p.m., with Director of Plant Operations, 2nd Dumpster closest to the fryer had its right-side lid open. The third dumpsters in the front were a piece of white paper lying on the ground half a foot diagonal to the dumpster that still remained. Observation on 02/22/2023 at 5:20 p.m., with Director of Plant of Operations, behind the kitchen entrance were serval emptied cardboard boxes lying on the ground. Interview on 02/22/2023 at 5:15 p.m., the Director of Plant Operations stated the dumpsters are to be cleaned of any trash everyday by him and by anybody. The Director of Plant Operation stated the dumpster lids are to remain closed and that the lids were in bad condition. The Director of Plant Operations stated he is responsible for taking care of the grounds and making sure the dumpster areas and around the facility are cleaned. The Director of Plant Operations stated he does not have the staff to be able to take care of the task like it should be. The Director of Plant Operations stated the risk to the residents is they could get sick. Record review of facility Related Garbage and Refuse Disposal dated 10/2007 stated food related garbage and refuse are disposed of in accordance with current state laws. Line. All food waste shall be kept in containers. Line 2. All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. Line 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. Line 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Record review of facility Waste Disposal dated 04/2022 stated food and nutrition services will ensure that waste containers are properly maintained. Line 1. Waste containers and dumpsters have lids covering them when not in use and are not overflowing. Line 2. Area around dumpsters are kept clean and odor and rodent free. Line 3. Dumpster plug are to be in place if not a sealed unit. Record review of facility Pest Control dated 05/2008 stated our facility shall maintain an effective pest control program. Line 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 675927 Page 22 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain medical records on each resident that are complete, accurately document and readily accessible for 11 of 16 residents (Resident #180, 62, 50, 71, 42, 62, 47, 15, 53, 41, and 8) reviewed for medical records. A. The facility failed to maintain physician orders that were complete and accurately documented for Resident # 180, 62, 50, 71, and 42. B. The facility failed to have history and physicals readily accessible for Resident #39, 38, 52, 180, 62, 47, 15, 53, 41, and 8. C. Resident #68 was receiving oxygen with no physician order. These failures placed residents at risk of not receiving necessary care due to inaccurate and or incomplete medical records. Findings include: Record review of Resident #39 History and Physical was not provided by facility at time of exit. Record review of Resident #38 History and Physical was not provided by facility at time of exit Record review of Resident #52 History and Physical was not provided by facility at time of exit Record review of Resident #180 History and Physical was not provided by facility at time of exit. Record review of Resident #62 History and Physical was not provided by facility at time of exit Record review of Resident #47 History and Physical was not provided by facility at time of exit. Record review of Resident #15 History and Physical was not provided by facility at time of exit. Record review of Resident #53 History and Physical was not provided by facility at time of exit. Record review of Resident #41 History and Physical was not provided by facility at time of exit. Record review of Resident #8 History and Physical was not provided by facility at time of exit. Record review of Resident #62 physician orders revealed there was no order for placement in the locked unit. 675927 Page 23 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #180 physician orders revealed there were no orders for placement in the locked unit. Record review of Resident #50 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Residents Affected - Some Record review of Resident #71 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Record review of Resident #42 active physician orders for February 2023 revealed no orders to be placed on secured memory unit. Observations on 02/21/23 at 9:05 AM revealed Resident # 62 was in secured locked unit. Observations on 02/21/23 at 9:12 AM revealed Resident #180 was in secured locked unit. Observations on 02/21/23 at 9:35 AM revealed Resident #50 was in secured locked unit. Observations on 02/21/23 at 9:40 AM revealed Resident #71 was in secured locked unit. Observations on 02/21/23 at 9:45AM revealed Resident #42 was in secured locked unit. Observations on 02/21/23 at 10:30 AM revealed Resident #68 was wearing a nasal canula with 3 liters of oxygen. Review of Resident #68's face sheet dated 02/23/23 revealed an [AGE] year-old male with and admission date of 12/02/22. Review of Progress notes dated 02/13/23 revealed Resident #68 supplemental o2 tank that remains in in his w/c was replaced by this nurse. Encouraged staff to ensure Resident #68 is on continuous o2 via N/C. Review of physician orders revealed there were no orders for oxygen or oxigenation monitoing. Review of comprehensive care plan dated 01/05/23 revealed ineffective breathing pattern related to COPD and CHF. (COPD is a lung disease that causes airflow limitation. CHF is a heart disease that causes shortness of breath due to overload of fluid). Goal was that Resident #68 would demonstrate effective breathing rate through interventions such as monitoring respiratory rate, and administer oxygen as ordered. Review of admission MDS assessment dated [DATE] revealed Resident #68 had a BIMS score of 5; indicating he was severely cognitively impaired. That meant he may have had impaired memory and difficulty with decisions. Section O revealed that Resident #68 had oxygen therapy. In an interview on 02/23/23 at 10:36 AM with the DON, she said Resident #68 did not have order for oxygen or oxygenation monitoring . She said her nurses had to make sure there were orders for oxygen if the resident was on oxygen in order to ensure the residents were receiving getting oxygen and being monitored . 675927 Page 24 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0842 Interview on 2/24/23 at 8:40 AM requested History and Physicals from DON. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/24/23 at 10:12 AM with LVN F, she said she was responsible for Resident #68 for that day. She said she knew Resident #68 had oxygen and said he had an order for it. (At this time, she was asked to look at his physician orders.) She said, he did not have orders for oxygen or pulse oximeter monitoring. She said part of her job was to look through all the orders, but she had not noticed it. She said it was important for Resident #68 to have an order for oxygen and pulse oximeter monitoring because he had COPD, and his oxygen could drop. She said she had been trained, but it had been a while. Residents Affected - Some On 02/23/23 at 10:41 AM, the DON reported there was no oxygen policy for the facility. Interview on 2/24/23 at 12:30 PM the DON stated history and physicals and physician orders should be readily available either on PCC or in the resident chart. The DON stated the facility was going through an all-electronic transition and it has been taking her a long time to obtain physician orders and history and physicals because Medical Records had boxes full of documents and she was needing to go through each one of them. Observation and interview on 2/24/23 at 12:50 PM revealed the Medical records room had approximately more than 10 big boxes filled with medical records, not sealed. Medical Records was on the phone with MD, stated she was trying to obtain history and physicals. Medical Records stated that new admissions history and physicals should be either on resident chart or PCC. Medical Records stated residents who had been residing in the facility long term should have history and physicals and physician orders in resident charts or PCC. Medical Records stated the facility was transitioning to all-electronic and had to go through boxes to file them. Medical Records stated there had been a set back when the pandemic hit. 675927 Page 25 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

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. Residents Affected - Some A. The facility failed to ensure Nasal Cannulas were placed in a bag when not in use for Resident #130, 11, 13, 70, 24, and 12. B. The facility failed to ensure clean linen was distributed in a covered linen cart, all four edges were torn exposing clean linen. C. The facility failed to keep urinals clean. D. The facility failed to ensure soiled linens were properly handled. These failures could place residents at risk of cross contamination. Findings include: Observation on 2/21/23 at 8:57 AM revealed the linen cart was on 200 hall. The linen cart was ripped on all 4 corners exposing clean linen. Observation on 2/21/23 at 10:02 AM revealed Resident #130 was not in the room; the nasal cannula was not bagged and on the floor. The urinal was at the top of the fridge at bedside next to a slightly opened bag of popcorn. The urinal was not in a bag and the rim and bottom was dark yellow, urine odor noted. Observation on 2/21/23 at 10:44 AM revealed Resident #11 was not in the room; the nasal cannula was on the floor not bagged, carpeted area. Observation on 2/21/23 at 10:49 AM revealed Resident #13's oxygen mask was not bagged; it was located hanging off behind the bedside dresser in the room. Observation on 2/21/23 at 10:54 AM revealed a dusty urinal was in on the restroom floor of room [ROOM NUMBER]. Observation on 2/21/23 at 11:22 AM revealed Resident #70's nasal cannula was on the floor and not bagged in the room, carpeted area. 675927 Page 26 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 2/21/23 at 11:53 AM revealed Resident #24's nasal cannula was not bagged and on the floor. Yankauer suction (a firm plastic suction tip with a large opening surrounded by a bulbous head and is designed to allow effective suction) was not bagged. Both located in Resident #24 room. Observation on 2/21/23 at 3:13 PM revealed the urinal was hanging off the towel rack next to the toilet, the urinal had yellow stain at the bottom . Observation on 2/22/23 at 11:40 AM revealed a ripped linen cart was being used to transport linen to the 200 hall, exposing clean linen. Observation on 2/22/23 at 5:04 PM revealed Resident #12's nasal cannula was not bagged and on the floor, caprpeted area. Yankauer suction was not bagged. Both located in Resident #12 room. Observation and interview on 2/22/23 at 6:34 PM revealed wet towels and sheets were on the floor of the 400 hall shower room. The DON stated the CNA's were trained to place all dirty, wet linen in the dirty bin. The DON stated they staff usually have dirty linen bin right outside the shower room for easy access to place dirty linen. The DON stated nursing staff were trained upon hire and annually . Interview on 2/23/23 at 11:25 AM the DON stated nasal cannulas and yankauer were required to be placed in bags when not in use. The DON stated all nursing staff were in charge of ensuring nasal cannulas and yankauer suction were properly stored while not in use upon hire and annually. The DON stated nursing staff were trained to check at least every two hours during rounds. The DON stated by not ensuring they were bagged when not in use could potentially put residents at risk of respiratory infection due to cross contamination. The DON stated urinals were required to be bagged when not in use and if seen dirty to be discarded. The DON stated by not cleaning urinals properly and storing them in bags when not in use could expose residents to infection due to cross contamination. The DON stated the facility did not have a policy on oxygen monitoring or infection control. Record review of Environmental Services: laundry and Linen processing policy dated 10/24/22 revealed page 1- The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Bagging and Handling Soiled Linen: 1. All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Page 2-Washing Linen and other Soiled Items: 7. Clean linen will remain hygienically clean (free from pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. Record review of Elimination: Ben Pan/ Urinal-Use policy dated 04/2021 revealed Page 1- Policy: It is the policy of this community to provide the bedpan/ urinal in a manner which is safe and promotes the resident's dignity. Page 2- Emptying Urinal or Bedpan: 5. Empty, rinse, clean, and replace urinal or bedpan. 675927 Page 27 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 facility reviewed for environment. The facility failed to ensure housekeeping and maintenance services were provided for resident living areas. This failure could affect residents placing them at risk of living in an unsafe, uncomfortable environment, infection and disease, and decreased quality of life due to poor conditions of the facility interior and exterior. Findings includes: Observation on 02/21/2023 at 9:22 a.m., the back yard green gate between the 200 hall and 400 hall was left wide open. No locks were noted on the gate. The gates were open to the desert. Observation on 02/21/2023 at 9:31 a.m., revealed resident room [ROOM NUMBER] had no doors on the left side of the closet exposing the clothes had no hinges attached. As soon as exiting the hallway to the left at average height level four screw size holes where some object was placed on the wall that were not covered. A thin strip of metal shown through while paint was cracked. Restroom shower had resident personal belongings in two brown boxes, two metal side rails, a white tapware two shelved storage box with a hospital grown on top. Two articles of clothes green and dark green shirts are hung on the shower pole. A picture frame, an elegant box, two hospital clear measuring sample urine containers with a blue ice pack looking object sit on top of the two boxes that are stacked together. On the wall where the call lights were hung, there was exposed wiring. Four orange electrical caps were seen and one blue capped electrical wire was seen. Two inches of the exposed wall to the left of the casing for the call light was exposed. Observation on 02/21/2023 at 9:49 a.m., revealed resident room [ROOM NUMBER] had no closet doors on both closets; the closet to the right did not have any hinges. Resident clothes on both closets were exposed. On the wall opposite side of the restroom there were four holes making a shape of a rectangle with two screws size holes separated a foot away from the other two holes. The window right above was five screw size holes above the window seal about three feet apart and on hole was in the middle. Observation on 02/21/2023 at beginning 10:04 a.m., revealed resident room [ROOM NUMBER] the whole connecting the bathroom and the closet they're all had 3 scratches near the border closest to the floor around 4 feet and name. Two feet above the scratches there was another set of scratches three of them about four feet in length. The scratches on the top cut into the wall exposing the white sheetrock underneath and scratches on the bottom expose sheetrock and had some black markings. As soon as you come out of the hall to your right is two scratches separated around two feet with a depth of 1/8 inch of sheetrock missing. The top scratch was a foot an a half and the bottom scratch was around two feet. The edge or corner of the wall had chips coming off it from the border of the floor approximately three feet upwards towards the ceiling. The restroom wall where the hand soap was attached underneath shows where it was originally located. There are ten holes poked into the wall with paint coming off exposing the brown and white sheetrock underneath. Three holes have yellow dry wall 675927 Page 28 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some anchors and two have gray dry wall anchors. Wall closet to the resident's bed had four large scrapings with multiple smaller and thinner scratches and lots of dots where paint and sheetrock is exposed. The main large scratch had a dept of around half an inch. Observation on 02/21/2023 at 10:21 a.m., of resident room [ROOM NUMBER] revealed the following: Closet space had no closet door attached exposing the residents' clothes; restroom shower had no turn knob for the hot or cold water. The shower spray hose did not have a sprayer. The floor drain was covered with 4 strips of duct tape with approximately a foot long. Shower floor tile looked dirty/stained and within the borders of the tile there was parts that had grime and dark in color while other areas were white. Observation on 02/21/2023 at 12:25 p.m., the conference room door handle in hallway 200 was dirty and had some unknown substance was light brown with little particles in it. When grabbing the door handle the foreign object was rough and grimy. Observation on 02/21/2023 at 12:28 p.m., in the front of the building the whole outside window screen was off lying sideways on the ground next to the window. Resident's window was closed. Observation on 02/21/2023 at 1:58 p.m., in resident room [ROOM NUMBER] the right-side closet is missing a door and the residents clothes is exposed. Observation on 02/21/2023 at 2:19 p.m., resident restroom [ROOM NUMBER] underneath the rail shows where the toilet paper dispenser was moved. Above it mesh was seen inside of the pinkish wall of the two exposed holes about two inches in diameter. The mesh looks like it is breaking outwards and between the two holes is a smaller hole about a dime size. An unknown material possible insulation is seen encircling some white spackle. Observation on 02/21/2023 at 2:21 p.m., in resident room [ROOM NUMBER] on resident wall had three small sized screw holes. On another wall near the cable cord was another three small sized screw holes. Observation on 02/21/2023 at 2:32 p.m., in resident room [ROOM NUMBER] the left side closet was missing a door and was missing one hinge exposing the residents' clothes. Below near the floor corner the border was gone exposing pieces of material. Observation on 02/21/2023 at 3:26 p.m., in resident room [ROOM NUMBER] the closet did not have any closet doors but instead had curtains that were orange hung up in place of the closet doors. Observation on 02/21/2023 at 4:02 p.m., in the Chapel currently used as the conference room in hall 200. The back door did not latch and remain unlocked. A resident was observed wandering the 200 hall and trying to get into the conference room multiple times with and without staff providing supervision. Observation on 02/22/2023 at 4:27 p.m., with Director of Plant Operations, in hallway 200 in the far back of the hall was a fire door exit that had a box on the top right hand with no covering exposing computer wiring and the mother board. Observation on 02/22/2023 at 4:46 p.m., in resident room [ROOM NUMBER] in the shower was a red luggage and a black larger luggage in the corner. On top of the red medium size luggage was a square 675927 Page 29 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blue linen bag and on top of the bag was a plastic hospital urinal with the cap open. The urinal had three doted areas color brown. A foot away to the other side of the shower floor was two wheelchair footrests. Tile on the shower floor looked dirty and in between the borders of the tile looked grimy and had dark area through the shower floor. Observation on 02/22/2023 at 5:06 p.m., with Director of Plant Operations revealed the front of the building porch had one of the support beams that had come off. The long piece of wood was lying on the ground on the side of the porch in the grass. This exposed the beam which was brown, and the plywood which was a grayish color. A foot long string of plywood was dangling in the air. On the side of the beam was approximately a four-foot piece of plywood. Observation on 02/22/2023 at 5:09 p.m., outside on in the front of the building was the outside screen the was bent outwards from the top half and the bottom half and not properly secured in the window frame. The window of the resident is closed. There was a tarantula that was dead with its limbs closed up like a hand making a fist. A large spider that appeared not alive was lying on the window ledge near the window's locking mechanism. Observation on 02/22/2023 at 5:19 p.m., in the back of the facility next to the kitchen was an outside window screen lying on the floor. The sliding window was closed. Observation on 02/22/2023 at 5:20 p.m., in the back gate area of the facility towards the outside of Hall 300 was an outside screen lying sideways on the wall towards the right side of the window. Observation on 02/22/2023 at 5:21 p.m., in the conference room of hallway 500 there are three windows with blinds that are broken, bent, distorted, or missing pieces of the blinds. Observation on 02/22/2023 at 5:25 p.m., in the activity and dining room of hallway 300 in the right corner close to the backyard between 300 and 500 hallways. There was exposed wiring from the border that was popped out exposing wiring around 4 feet from the wall. A residents sat on a reclining chair two or three feet away. Observation on 02/22/2023 at 5:26 p.m., in the back yard area located inside the gate between hallways 500 and 300 there were two blue ACE buckets (one filled with water) stacked on top of each other while a third ACE bucket was lying on its side further down in the grass. To the left about two feet of the buckets was one white 3 by 4 feet piece of wood with a small 2 by 1 ½ foot piece of white wood leaning next to the wall of the 300 Hall resident room (Unknown whose room it is). Two feet to the left of the white pieces of wood was a bucket lid from the ACE bucket that was on the ground. Close to the fence line there was two blue mattresses the one on the bottom was torn and exposed 675927 Page 30 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0921 the white inner part of the mattress. Next to it was a large piece of wood around 6 feet in length. Level of Harm - Minimal harm or potential for actual harm Observation on 02/22/2023 at 5:30 p.m., in hallway 300 near the communal shower room wall was a 6-inch by 2-inch rectangle hole in the wall. The mesh is exposed and sheetrock. It is noted that residents are walking up and down the hallway. In the communal shower was two gray trash cans, two shower chairs, on the floor was a large bottle of a unknown chemical unsecured, unattended by staff and accessible to residents. The floor tile looked grimy, and borders had dark material in between them. To the right side of the shower was a laundry holder with a small gray basket underneath, to the side was a clear plastic bag full of clothes and wet shower boots, a white small trash can, and a normal trash can sat close. Above on the wall next to the paper towel dispenser was paint coming off exposing the brown plywood underneath. Residents Affected - Some Observation on 02/24/2023 at 10:08 a.m., in resident room in the 500 hallway. The shower had three brown boxes stacked on top of each other on the floor and a dresser drawer on top of them in the corner. A black ladder that was able to hold items. Underneath behind the black ladder was another small brown box with items and a shoe on it. In front to the side corner was a medium sized brown box with other items. Tile floor was dirty and in between the borders had dark material throughout the floor. Interview on 02/21/2023 at 3:26 p.m., with Resident #76 stated that her son came and bought curtains because the closet did not have doors. Resident #76 stated she liked the curtains but wanted to have the closet doors. Interview on 02/22/2023 4:10 p.m., Director of Plant Operations stated anything the nurses find broken or wrong through the facility must be written down. Director of Plant Operations stated he tried to fix repairs as soon as possible and prioritizes the repairs like if there is no water or the toilets are not working then those issues are worked on first. Director of Plant Operations stated in the maintenance log under descriptions he places what he has done to correct the repair issues. Director of Plant Operations stated some facility staff will verbally come and tell him about the discrepancy instead of writing it down in the maintenance log. Director of Plant Operations stated he does not record discrepancy anywhere else other than the maintenance log. Director of Plant Operations stated he had gone to the nurses and reported telling them verbally to write down any issues in the maintenance logbook. Director of Plant Operations stated he had not in-serviced the facility staff on what to do or how to notify him on where to request work orders. Director of Plant Operations stated the Administrator had reported the conference door not locking a week ago and was not recorded in the maintenance log. Interview on 02/22/2023 at 5:00 p.m., with Director of Plant Operations stated the transport vehicle does not park directly beneath the beam that had repair issues. Director of Plant Operations stated the transport for the resident sparks further away underneath the front porch overhang. Director of Plant Operations stated that a month ago a commercial vendor delivering items had ripped that portion of the overhang and the commercial vendor was going to pay for it but had not yet made the repairs. Director of Plant Operations stated that a lot of the window screen that are off do not fit the windows anymore. Director of Plant Operations stated it was probably due to the frames being warped and bent. Director of Plant Operations stated the outside window screen did not fit. Director of Plant Operations stated that the outside screen was bent and did not properly make a seal to create a barrier from the outside to the inside environment like a lot of other window screens. Director of Plant Operations stated he had not had time to fix the issue because it was only him and he did not have staff and was busy with other tasks. Director of Plant Operations stated the facilities gates 675927 Page 31 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some need to be closed and locked. Director of Plant Operations stated the gate locks broke and have not been replaced. Director of Plant Operations stated the gate needs to be closed and locked especially since the conference room door does not lock. Director of Plant Operations stated resident room [ROOM NUMBER] shower had resident personal belongings in it and CNAs use it as storage. Director of Plant Operations stated resident room [ROOM NUMBER] hole in the wall with the call light was not repaired properly by contractors the facility has to repair call light systems. Director of Plant Operations stated he oversees that the contractors are properly doing the work right. Director of Operations stated the wires being exposed was an electrical fire hazard and a risk to the residents. Direct of Plant Operations stated he does not do daily checks of rooms throughout the facility. Director of Plant Operations stated resident shower in 508 tile was mold on the floor. Director of Plant Operations stated the Housekeeping Supervisor was supposed to oversee that the housekeepering personnel are cleaning thoroughly all of the rooms and showers. Director of Plant Operations stated the mold could be a hazard to residents by getting them sick. Director of Plant Operations stated that most of the restrooms are dirty. Director of Plant Operation stated he would not want to take a shower in the facility's shower. Director of Plant Operations stated it did not look like housekeeping was cleaning everyday and properly. Director of Plant Operations stated the House keeping Supervisor oversees the and makes sure the cleaning is being done. Director of Plant Operations stated that they do have chemicals that are strong enough to remove and kill the bacteria/strains. Director of Plant Operations stated the housekeepers are trained in their job duties. Director of Plant Operations stated the shower room in resident room [ROOM NUMBER], the duct tape was placed there to keep a resident from urinating into the drain and from stopping the resident from also placing foreign objects into the drain. Director of Plant Operations stated the fire door in hallway 200 had the electrical conjunction box covering missing and was a fire hazard to the residents due to the exposed components. Interview on 02/23/2023 at 8:55 a.m., the Administrator stated regarding the shower in resident room [ROOM NUMBER], he had not seen that the showers were being used as a storage with residents personal belongings. The Administrator stated that it was the right of the resident if they wanted their belongings placed in the shower. The Administrator stated that they have to look at the resident's diagnosis and if the representatives wanted the belongings in the shower. The Administrator stated the shower in resident room [ROOM NUMBER] looked like the tile had mold (Administrator grabbed a wipey and wiped some of the black matter from the tile side wall and floor) and that the housekeeping supervisor needed to make sure the housekeepers were cleaning. The Administrator stated the communal shower room in the 200-hall had water strain on the floor and wall tiles. The Administrator stated the facility had chemicals to be able to remove the mold looking material in the communal shower room. The Administrator stated they are in the process of trying to remodel the restrooms. The Administrator stated the risk to the residents using the shower would be infection. Interview on 02/23/2023 at 8:58 a.m., Resident #20 stated she did not know about her luggage and other personal belongings being stored in her restroom shower. Resident #20 stated no one from the facility staff or during admission told her if she wanted her personal belongings in the shower. Resident #20 stated to the Administrator that she wanted her personal belongings removed from the shower immediately because she did not give permission to have it placed in there. Interview on 02/23/2023 at 9:45 a.m., with Director of Environmental Services stated that all housekeepers have to be trained to conduct housekeeping. Director of Environmental Services stated that for trainings they had a sign in sheet where the housekeeping staff would sign off but not anymore. The Director of Environmental Services stated she was in charge of making sure the housekeepers were cleaning. The Director of Environmental Services 675927 Page 32 of 33 675927 02/24/2023 Focused Care at Crane 699 Campus Dr Crane, TX 79731

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she does checks on her staff but tries to have confidence in them that they are doing what they are supposed to. The Director of Environmental Services stated that the housekeepers were supposed to be cleaning every day. The Director of Environmental Services stated the restroom and the residents' rooms were to be cleaned. The Director of Environmental services stated every day housekeeping was to be vacuuming. The Director of Environmental Services stated she was conducting her rounds and was finding that at times the housekeeping was not being done right. Director of Environmental Services stated she tells the housekeepers to do a task and ends up having to redo the task because it was done incorrectly. The Director of Environmental Services stated she had not in-serviced the housekeeping staff. The Director of Environmental Services stated there was two housekeepers in the morning and one in the afternoon. The Director of Environmental Services stated she was short staffed. The Director of Environmental Services stated resident shower room in 508, she had not seen it yet. The Director of Environmental Services stated she had been working at the facility for ten years and had seen the way all the showers were and did not voice the uncleanliness to her superiors. The Director of Environmental Services stated the risk to the residents was breathing. The Director of Environmental Services stated that the dark material looked like mold that had mushrooms or spores that could affect the residents with breathing. the Director of Environmental Services stated resident shower in 209 had personal belongings with a urinal container sitting on top of the belongings and did not belong there. The Director of Environmental Services stated if she was a resident there, she would not like the urinal with her personal belongings. The Director of Environmental Services stated she would not have the restrooms dirty like that in her home. Interview on 02/23/2023 at 10:30 a.m., with Housekeeper D stated she had received training to be a housekeeper from two staff that no longer work at the facility. Housekeeper D stated the housekeeper trainers demonstrated how to clean first and then she did. Housekeeper D stated she did receive formal training from the facility where she signed off. Housekeeper D stated the housekeepers clean all the rooms in all the halls. Housekeeper D stated carpets are cleaned every day. Housekeeper D stated the shower in resident room [ROOM NUMBER] does not look clean but she does mop it. Housekeeper D stated she would not shower in the shower but only use the toilet if she was a resident. Housekeeper D stated she had seen how the showers look and had not voiced it out to her supervisors regarding the issue of the mold and dirtiness. Housekeeper D stated regarding resident shower in room [ROOM NUMBER], she would not like that urinal and the luggage do not look good being in the shower. Housekeeper D stated she did not know why the urinal was in the shower since the residents in the room were all female. Record review of facility Maintenance Log reviewed indicated there were only two work orders requested. The orders were for 02/16/2023 for rooms 306 and room closet 300. Record review of Resident #20's face sheet and MDS indicated that resident was her own Representative and had a BIMS of 8. 675927 Page 33 of 33