Health inspection·January 11, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. Residents Affected - Many The facility failed to ensure the dish machine tested at the required 50-100 PPM and the water temperature reached the required 120 degrees Fahrenheit required for proper sanitation in a low temperature, chemical sanitizer dish machine. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 01/09/23 at 10:13 A.M., the DA, ran the dish machine to get the water temperature to the required 120 degrees F for proper sanitation in a low temperature, chemical sanitizer dish machine. The water temperature was 114 degrees F. She then took a chemical sanitizing test strip and dipped it into the water of the dish machine. The test strip indicated 10 ppm. The DA had been washing the breakfast dishes and the calendar on the wall indicated she had tested the dish machine at the start of her shift on 01/09/23 and the water temperature was 113 degrees F, and the chemical sanitation level was at 50 ppm. The Dining Service Director made three additional attempts to test the machine, and recalibrated the machine, getting air bubbles out of the liquid sanitizer line. The sanitizer tested at 50 PPM, but the water temperature was still low at 114 degrees F. A calendar dated January of 2023 indicated: Water Temperature in degrees F: Breakfast: Lunch: Dinner: 1st-120 118 100 2nd-113 118 115 3rd-112 116 118 Page 1 of 7 675964 675964 01/11/2023 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0812 4th-116 118 118 Level of Harm - Minimal harm or potential for actual harm 5th-113 118 0 6th-115 116 118 Residents Affected - Many 7th-113 118 116 8th-115 117 118 9th-113 120 121 10th-122 During an interview on 01/09/23 at 10:20 AM, the DA said she had worked at the facility for 3 years and was trained by a Chef, who was no longer at the facility. The DA said she told the Dining Service Director that the machine was not getting the water hot and the technician came and looked at it about a week and a half ago but did not fix it. The DA said the residents could get sick if the dish machine was not sanitizing the dishes properly. During a record review on 01/09/23 at 10:30 PM of the January calendar the lowest temperature recorded was 112 degrees F. and the highest was 116 degrees F. which did not meet the required water temperature of 120 degrees F. for a low temperature machine. During an interview on 01/09/23 at 11:00 AM the Dining Service Director said it was his responsibility to train his staff to test the dish machine correctly and notify him, or maintenance when the water temperature does not meet the required 120 degrees F and the sanitizer does not reach 50-100 PPM. During an interview on 01/11/23 at 2:02 PM, the ADM said going forward, he expected the staff to check the machine every shift and notify the Dining Service Director if the machine does not reach the required water temperature of 120 degrees F and sanitation level of 50-100 PPM. He said there would be additional training for the staff on testing the machine. A POLICY # F019: Sanitation and Infection Prevention/Control Subject: Dishwashing Temperatures Revised January 2022 indicated: LOW TEMPERATURE DISHWASHER (Chemical Sanitation): *Wash 120 F; and * Final Rinse 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. The wash period shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees. 675964 Page 2 of 7 675964 01/11/2023 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0812 Level of Harm - Minimal harm or potential for actual harm h. Facilities shall use an approved test kit to measure the parts per million (ppm) of the chemical solutions in the low temperature dish machine daily. Any abnormal test results shall be reported to the CMD. A ppm of 50 will be attained prior to dishes being washed. Residents Affected - Many 675964 Page 3 of 7 675964 01/11/2023 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents reviewed for infection control. (Resident #9, Resident #23, and Resident #56) Residents Affected - Some 1. CNA A did not wash or sanitize her hand when changing gloves while performing incontinent care for Resident #9. 2. CNA B and LVN E did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #56. 3. CNA C and CNA D did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #23. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of a Face Sheet dated 01/10/2023 for Resident #56 indicated he admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included cerebral infarction (a lack of adequate blood supply to the brain), dysphasia (unable to swallow food or liquids), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection, moderate protein-calorie malnutrition (means you are not receiving enough protein or calories), cognitive communication deficit (difficulty with thinking and how someone uses language) and gastrostomy status (feeding tube in the stomach), benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). Record review of a care plan, dated 9/30/2022 for Resident #56, indicated he had urinary incontinence with an approach to provide extensive to total assistance by 1 staff for incontinent care. Record review of a Quarterly MDS assessment dated [DATE] for Resident #56 indicated he was interviewable with a BIMS score of 12. He required total dependence with one-person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. He was always incontinent of bowel. Bladder was not rated due to having suprapubic catheter in place. During an observation on 1/10/2023 at 10:10am in Resident #56 room revealed, CNA B and LVN E were present to provide incontinent care. Both staff washed their hands in the bathroom in Resident #56's room and applied gloves. CNA B and LVN E positioned Resident #56 in supine position then turned him on his left side to perform his incontinent care. LVN E removed the Velcro fastener on the right side of residents brief and rolled the brief to the residents left back side. LVN E removed a wipe from a container and cleaned his rectal area wiping from front to back, LVN E repeated this step 6 times until residents' rectal area did not have and visible bowel movement. LVN E placed the wipes in the trash bag leaving soiled brief in place and LVN E unrolled a clean brief and placed at residents' buttocks area. LVN E then performed wound care to wounds on sacrum. After completing wound care without changing gloves, sanitizing, or washing hands LVN E repositioned clean brief to buttocks area and pushed the soiled brief under residents left hip and placed her hands on residents' right hip to 675964 Page 4 of 7 675964 01/11/2023 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some guide resident to roll onto clean brief. CNA B reached under resident to remove soiled brief and wrapped soiled brief and attached Velcro fasteners around brief to secure it and placed it in the trash bag, without changing gloves, sanitizing, or washing hands CNA B applied Velcro strips on clean brief on residents left side to secure brief around resident. LVN E and CNA B then adjusted residents clothing, bed linens and pulled resident up in bed without changing gloves, sanitizing, or washing hands. LVN E and CNA B then doffed their gloves and washed their hands in resident's bathroom before exiting resident's room. During an interview on 1/10/23 at 11:11 AM, LVN E said she had been employed at the facility for about 2 years as ADON and treatment nurse. When she was asked if she would have done anything differently with the incontinent care provided to Resident #56, she said she should not have touched dirty and clean briefs with the same gloves. She says she should have changed gloves and washed hands after performing incontinent care. She stated she received multiple in-services and trainings related to handwashing, PPE, and brief sizing. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 1/10/23 at 11:11 AM, CNA B said she had been employed at the facility as the restorative CNA. When asked if she would have done anything differently with the incontinent care provided to Resident #56, she said she would admit that she messed up and she should not have touched dirty and clean briefs with the same gloves. She says she should have changed gloves and washed hands after performing incontinent care. She stated she received multiple in-services and trainings related to handwashing, PPE, and brief sizing. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves During an interview on 01/10/2023 at 10:23 AM, DON said he expected hand washing to be done between anything soiled. DON said he expected to increase his in-services on hand washing, setting up cart for wound care, not transferring infection from area to the next, and clean versus dirty. She said a resident could be at risk for infections, if staff did not wash or sanitize their hands between gloves changes. 2. Record review of a Face Sheet dated 01/11/2023 for Resident #23 indicated he admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included Alzheimer's disease (disease that destroys memory and other mental functions), dementia (destroys 2 brain functions), chronic kidney disease Stage 3 (as kidneys fail waste builds up), overactive bladder, chronic Embolism, and thrombosis of unspecified popliteal vein (blood clot in the vein), Obesity (excessive body fat). Record review of a care plan dated 9/28/2022 for Resident #23 indicated he had bowel and bladder incontinence with an approach to provide incontinent care every 2 hours and as needed. Record review of a Quarterly MDS dated [DATE] for Resident #23 indicated she has severe impaired cognition with a BIMS score of 02. She required extensive to total dependence with one-person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene. During an observation on 1/11/2023 at 10:02am of Resident #23 's room revealed CNA C and CNA D were present to provide incontinent care. Both staff washed their hands in the bathroom in Resident #23's room and applied gloves. CNA C and CNA D positioned Resident #23 in supine position to perform his incontinent care. CNA C removed the Velcro fastener on the sides of residents brief and rolled the brief toward the residents back. CNA C removed a wipe from a container and cleaned her peri area wiping from front to back, CNA C repeated this step 3 times. CNA C and CNA D doffed gloves and placed 675964 Page 5 of 7 675964 01/11/2023 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some them in the trash can and doffed new gloves without sanitizing or washing hands. CNA C rolled Resident #23 to her left side with the assistance of CNA D, CNA C removed the soiled brief and handed it to CNA D and CNA D placed soiled brief in trash can. CNA C placed the wipes in the trash. CNA C and CNA D doffed gloves and placed them in the trash can and doffed new gloves without sanitizing or washing hands. CNA C unrolled a clean brief and placed at residents' buttocks area. CNA C attached Velcro fasteners around brief to secure it, without changing gloves, sanitizing, or washing hands. CNA C and CNA D then adjusted residents clothing, bed linens and pulled resident up in bed without changing gloves, sanitizing, or washing hands. CNA C and then doffed her gloves and washed her hands in resident's bathroom before exiting resident's room. CNA D doffed gloves and did not was or sanitize hands before leaving resident's room. During an interview on 1/11/2023 at 10:25 AM, CNA C said, when asked what she would do differently, she said that she would have hand sanitizer with her. She said she would have washed her hands more and, would have had the table closer to her. When asked about infection control CNA C stated that she would have brought hand sanitizer and washed her hands more. During an interview on 1/11/2023 at 10:29 am, CNA D said, when asked if she would do anything differently, no, and that it had been too long since she has done incontinent care for state, then stated that she would have positioned the resident differently. When asked about infection control CNA D stated she would not have done anything differently. 3. Record review of an admission Record for Resident #9 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia (weakness on one side), hydronephrosis with renal and ureteral calculous (backup of urine in the kidneys), and major depressive disorder (feeling of sadness or loss of interest constantly). Record review of a Quarterly MDS Assessment for Resident #9, dated 12/16/2022, indicated she did not have any impairments in thinking with a BIMS score of 15. She required extensive assistance with 1 person assist in bed mobility, dressing, and personal hygiene. She was totally dependent with toilet use and always incontinent of bowel and bladder. Record review of a care plan for Resident #9, dated 2/9/2019, with a revision on 3/1/2021 indicated a focus that she required assistance with ADL's and transfers. Interventions and tasks included to encourage and assist resident in turning/repositioning/incontinent care every 2 hours and PRN. She had a focus of bowel and bladder incontinence dated 3/31/2019 with a revision on 3/1/2021 with interventions/tasks to check every 2 hours and as required for incontinence. During an observation on 1/10/2023 at 11:10 AM in Resident #9's room with CNA A present. CNA A washed her hands in Resident #9's bathroom and applied gloves to her left hand and 1 glove to her right hand. CNA A pulled the linens back and Resident #9's brief down between her legs. CNA A removed wipes three times from the container and wiped Resident #9's vaginal area on both sides of her inner thighs and down the middle of her vagina. CNA A removed the glove from her right hand and placed it in the trash and placed another glove on her right hand. CNA A rolled Resident #9 to her left side and removed a wipe from the container 5 times and wiped stool front Resident #9's rectum front to back, back to front and on both sides. CNA A rolled brief and placed an under pad under Resident #9's buttocks. CNA A removed gloves from both hands and placed them in the trash. She applied gloves to both hands and placed a clean brief under Resident #9's buttocks. Resident #9 was rolled to her right side and dirty brief and under pad was removed. CNA A rolled the clean under pad, and brief under Resident #9's buttocks. CNA A removed the gloves from both hands and placed them in the trash. CNA A 675964 Page 6 of 7 675964 01/11/2023 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some applied gloves to both hands and removed linens from the room and placed them in the dirty linen closet. CNA A washed her hands in the dirty linen closet. During an interview on 1/10/2023 at 11:25 AM, CNA A said she had been employed at the facility for over a year, but only worked prn at the facility. When asked if there was anything she would have done differently with incontinent care, she said would have only wiped from front to back and not in both directions. She said she had received trainings on patient care, incontinent care, and every month the staff at the facility were assigned different topics to complete online. She said she should have washed or sanitized her hands with each glove change. She said a resident could get an infection if staff didn't wash hands with glove changes and wiping a female resident from back to front. During an interview on 1/11/2023 at 11:35 AM, the DON said he had been employed at the facility since July 2022. He said he expected hand washing to be done between anything soiled. DON said he expected to increase his in-services on hand washing, setting up cart for wound care, not transferring infection from area to the next, and clean versus dirty. He said a female resident should be wiped from front to back and that the staff knew that. He said a resident could be at risk for infections if staff did not wash or sanitize their hands between gloves changes. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated, .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. after removing gloves . Record review of a facility policy titled Perineal Care with a revised date of February 2018 indicated, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. For a female resident: b. Wash perineal area, wiping from front to back. e. Wash the rectal area thoroughly, wiping form the base of the labia towards and extending over the buttocks . 675964 Page 7 of 7