Health inspection·October 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure the resident has a right to a safe, clean, comfortable and homelike environment for 2 of 4 (Resident #1 and Resident #2) residents reviewed for environmental concerns. The facility failed to ensure that the Resident #1 and Resident #2's bedding, and Resident #1's air mattress were clean and free of dirt and dried food. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Record review of Resident #1's admission Record dated 10/09/2024 revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's medical diagnoses included Alzheimer's disease (brain disorder that gets worse over time), dementia (memory, thinking, difficulty), muscle weakness, lack of coordination, weakness, morbid obesity, type 2 diabetes mellitus without complications (high blood sugar), protein-calorie malnutrition, kidney disease, sepsis (a life threatening complication of an infection), cholecystitis (inflammation of the gallbladder), bacteremia (infection in the blood stream), malaise (feeling of general discomfort), major depressive disorder, COVID 19, dysphagia (difficulty swallowing), abnormal weight loss, chronic pain, and cognitive communication deficit (problems with communication). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 01 indicating the resident had severe cognitive impairment. Record review of Resident #2's admission Record dated 10/09/2024 revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #2's medical diagnoses included type 2 diabetes mellitus with unspecified complications (high blood sugar), cerebral infarction (long term effects of a stroke), end stage renal disease (end stage of kidney disease), hyperlipidemia (high cholesterol), hypertension (high blood pressure), and depression. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that Resident #2 had a BIMS score of 00 indicating the resident had severe cognitive impairment. Observation of Resident #1's room on 10/09/2024 at 8:02am revealed that the resident was asleep in her bed. The resident's comforter and a sheet were on the floor and there were visible food crumbs, Page 1 of 3 675937 675937 10/09/2024 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0584 Level of Harm - Minimal harm or potential for actual harm white and brown substance smeared on areas of the mattress and a large area that appeared to be wet or dark stained on the air mattress. Observation of Resident #1's room on 10/09/2024 at 10:12am revealed that the resident's comforter and sheet were still on the floor. The comforter had a dried orange substance on it that appeared to be food. Residents Affected - Few Observation of Resident #1's room on 10/09/2024 at 11:05am revealed that housekeeping was cleaning Resident#1's room. Observation after housekeeping on 10/09/2024 at 11:05am revealed housekeeping cleaned Resident #1's room and that the comforter (the resident's personal comforter) that was on the floor was made on the bed and the air mattress was not cleaned. Lifted the covers and flat sheet and the air mattress still had brown smeared substance and white smeared substance on it. There was also still crumbs of what appeared to be food on the air mattress. An interview with Resident #1 on 10/09/2024 at 11:06am was unsuccessful; Resident #1 would not talk to surveyor. An interview with Resident #1's POA on 10/09/2024 at 9:09am and 10:19am were unsuccessful and call was not returned. An interview with Resident #2's POA on 10/09/2024 at 11:24am revealed that she had an incident about a week before where Resident #2 had dried feces on her bed and her floor. She stated the staff had the let the cleaning solution soak on the floor and come back and clean it up because it had dried. Observation of Resident #2's room on 10/09/2024 at 11:38am revealed that her bed was made and in the middle of her bed was dried brown in color substance that was a little bigger than a quarter. Observation of Resident #2's room on 10/09/2024 at 12:50pm revealed that CNA A was sitting in a chair in Resident #2's room. Resident #2 was observed laying in the bed with the dried food still on the comforter sleeping. An interview with CNA A on 10/09/2024 at 12:50pm revealed that she was watching Resident #2 because she was getting into things and was all over the floor. She also said that the bedding is changed when it gets dirty. She said that the nurses and CNAs were responsible for changing the resident bedding. She said it was not good hygiene to have dirty bedding on a resident's bed. She also said that she did not notice the dried food on the resident's bed. An Interview with the DON on 10/09/2024 at 1:00pm revealed that staff had been trained in resident rights. She stated that the nursing staff were responsible for picking up the resident's rooms. She also said that the nurses and CNAs were responsible for ensuring the resident's bedding was clean. She said that anytime they were soiled the staff were expected to change them. She also said that housekeeping was responsible for wiping down the air mattress when they cleaned the residents' rooms. She said it was a hygiene issue. She stated she did not know why Resident #1 and Resident #2's bedding had dried food on them. An interview with the ADM on 10/09/2024 at 1:38pm revealed that staff were trained on resident 675937 Page 2 of 3 675937 10/09/2024 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rights. He said they did not have a housekeeping policy, but his expectation was if any staff saw the mattress was dirty then it should be cleaned. He said he was not aware that the resident's bedding was dirty. He also said he did not know why the bedding and mattress was not cleaned. An interview with CNA B on 10/09/2024 at 2:34pm revealed she had been trained on resident rights. She stated the CNAs were responsible for changing the resident's bedding and wiping down the air mattresses. She said that the air mattress was to be wiped down when the resident was gotten up and then it was to be air dried. She also said that when the resident's bedding was soiled, or dirty staff were supposed to send it to laundry to be cleaned. She said a resident would never have a blanket or sheet that was dirty. She said the resident may feel nasty or dirty if their bedding is dirty. She said by having dirty bedding the resident could get an infection. She did not know why Resident #1 or Resident #2 had dirty bedding and Resident #1's air mattress was dirty. An interview with CNA C on 10/09/2024 at 2:41pm revealed that she had been trained on resident rights. She stated the CNAs were responsible for picking up and keeping the resident's belongings in place. She said the resident's bedding and air mattress were cleaned the day the resident gets his or her shower. She also said that if the resident's bedding were dirty or the resident spilled something on it then staff would send it to the laundry to be cleaned. She said that by the resident's bedding not being cleaned the resident could get depressed, upset or feel uncomfortable. She stated she did not know why Resident #1 and Resident #2's bedding was dirty. An interview with LVN D on 10/09/2024 at 3:04pm revealed she had been trained on resident rights. She stated that the nursing staff were responsible for ensuring resident's belongings and bedding were clean. She said that was part of the residents' ADLs. She stated the air mattresses were cleaned daily because they did not have sheets on them. She also said that if the air mattress needed cleaning more often staff were to clean them more often. She said that the resident should always have clean bedding, and it should be put in a plastic bag and sent to laundry if it was soiled or dirty. She stated that residents should not be using dirty or soiled blankets or sheets. She said if the resident was bed bound then staff were to change the bedding and clean the resident up. She said residents would not be happy if they had dirty bedding. She said the resident could get ants in their room if they had dirty bedding. She said she did not know why Resident #1 and Resident #2 had dirty bedding. Record review of Homelike Environment Policy revised on February 2021 revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The community team members and management maximize to the extent possible the characteristics of the community that reflect a personalized homelike setting. These characteristics include clean, sanitary and orderly environment, clean bed and bath linens that are in good condition. 675937 Page 3 of 3