Health inspection·June 2, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 16 residents reviewed with limited range of motion (Resident #2), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #2 had interventions in place for her right- and left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right and left hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #2's Face Sheet dated 06/02/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Multiple Sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body), Contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and Hypertension ( High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache). Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 1 indicating severe cognitive impairment. Resident #2 was assessed to require extensive assist with all ADLs. Resident #2 was further assessed to have limitation in range of motion for both upper extremities. Review of Resident #2's Comprehensive Care Plan (not dated) reflected a problem for limited physical mobility related to contractures. Interventions did not include palm protectors. Review of Resident #2's Consolidated Physician orders dated 06/02/2023 reflected no orders for contracture management or palm protectors. Observation on 05/30/2023 at 10:25 AM revealed Resident #2 in room in bed alert but confused. Resident #2 was observed to have contractures of her bilateral hands. Resident #2's right hand had tissue Page 1 of 9 675979 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few paper between her fingers and her palms. Resident #2's fingernails were long. Observation of Resident #2's left hand revealed her fingers curled into her palm. Resident #2's fingernails were long and digging into her palm. Resident #2 was not able to open her hand. Observation on 06/01/2023 at 1:00 PM revealed Resident #2 in room in bed. Observation of Resident #2's hand revealed no palm protectors in resident's hands and fingernails remained long. In an interview on 06/02/2023 at 10:01 AM LVN E examined Resident #2's hand and stated that Resident #2 hand was contracted, and Resident #2 should have palm protectors in place. LVN E further stated Resident #2's fingernails were long, and they were digging into her palms. LVN E stated Resident #2 needed her fingernails trimmed and palm protectors in place to prevent Resident #2 from getting skin breakdown in her hands. LVN E stated it was not only the responsibility of hospice staff, but the facility nurses and CNAs to ensure the care was provided for Resident #2 . In an interview on 06/02/2023 at 10:11 AM CNA F stated she was not aware of any devices for Resident #2's hands to treat Resident #2's contractures. CNA F stated, Resident #2's hands are contracted, I don't know why they do not have palm protectors for her, but they should . In an interview and observation on 06/02/2023 at 11:35 AM the DON stated hand rolls or palm protectors should be used for residents with contractures. After the DON reviewed Resident #2's care plan she stated there were no interventions listed for contracture devices . The DON stated the nurses are responsible for ensuring care is provided and to ensure nail care is done. The DON stated the residents' nails should have been trimmed because it could lead to pressure ulcers or infection. Review of the facility policy Resident Mobility and Range of Motion dated July 2017 reflected Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion . 675979 Page 2 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervisions and assistive devices for 1 of 8 Residents (Resident #17) reviewed for accidents and hazards, in that: Facility failed to adequately supervise and ensure staff checked the coffee temperature prior to serving to residents which resulted in Resident #17 spilling a pot of coffee over his lap resulting in 1st and 2nd degree burns to his bilateral thighs and down his legs to his ankles. On 05/31/2023 at 2:40 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/02/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of accidents due to lack of supervision. Findings included: Review of Resident #17's Face Sheet, and health record information dated 06/02/2023 reflected an [AGE] year old male admitted on [DATE] with diagnoses which included dementia in other diseases with mood disturbance (refers to the presence of disturbed mood, behavior or thought confusion), psychotic disorder with delusions, acute heart failure, lack of coordination, muscle wasting and atrophy(loss of muscle leading to its shrinking and weakening.), gastro-esophageal- reflux disease without esophagitis, sick sinus syndrome ( abnormal heart beat), presence of pacemaker( machine to stabilize heart rate, major depressive disorder (a common mental disorder, It is characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), fractured( cracked) right hip. Review of Resident #17's Significant change MDS dated [DATE] revealed a BIMS score that was not determined indicating severe cognitive impairment. Resident #17 was assessed to require partial/ moderate assistance status for the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of Resident #17's care plan dated 05/24/2023 revealed Resident #17 to have dementia and poor nutritional intake requiring assistance supervision and/or cueing at each mealtime as indicated. Observation on 05/30/2023 and 5/31/2023 revealed no coffee outside of the satellite kitchen on the first or second floor dining room areas. Review of the facility reported incident completed by Administrator dated 05/27/2023 reflected Resident #17 was in the dining room prior to breakfast and went to get a cup of coffee. Resident #17 dropped the pot of coffee all in his lap. Resident #17 complained of pain and was sent to ER. Review of Resident #17's Hospital Records dated 05/27/2023 reflected Patient presents to emergency room from nursing home with reports that he had some hot coffee spilled on his legs. He has some 1st and 2nd degree burns to both thighs .after examination the patient has approximately 2-3% 675979 Page 3 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few second-degree burns (Second -degree burns, or partial thickness burns, are more severe than first-degree burns. They affect the outer layer of skin, called the epidermis, and part of the second layer of skin, called the dermis), with small amount of 1st degree burns (First-degree burns affect only the top layer of skin (the epidermis). patient with dementia and does recall that he spilled hot coffee on his legs. Review of an in-service provided to nursing staff by the DON dated 05/27/2023 reflected Hot beverages such as coffee and tea are available to our residents throughout the day The liquids are very hot and can cause significant burns. Make sure lids are screwed tightly on the pot .observe for cracks, chips, etc.Keep in mind our residents have the right to drink coffee and we should have it accessible to them, just keep an eye on them and make sure they are being safe . The in-service training did not address testing the temperature of the coffee. In an interview on 05/31/2023 at 10:55 AM the Administrator stated the facility did keep a metal coffee pot on the bar in the dining room area with coffee in it for the residents to self-serve. He stated they removed the coffee from the bar after the incident and now it is only in the satellite kitchen. He stated the facility did not have a policy for testing the temperature of the coffee before serving it or putting it out. In an interview on 05/31/2023 at 09:45 AM RN A stated while staff were getting residents up, Resident #17 was trying to get his own coffee. RN A was alerted by a dietary aide of Resident #17 having an accident spilling hot coffee on himself. RN A stated as she arrived at the scene of the incident, she observed a coffee lid and coffee pot placed separately on the floor so it looked like the coffee lid was not on correctly but that was only her assumption since she was not present at the scene. RN A stated when Resident #17 was bought back to his room, she noticed bright redness on both of thighs. RN A called the doctor for Resident #17 to be sent to the ER. RN B stated ER reported that Resident #17 had 2nd degree burns. RN A stated when he returned to the facility, she noticed he had blisters. RN stated Resident #17's doctor has him on Xero foam Gauze currently. RN A stated the coffee pots have been removed and are currently not accessible to the residents. RN A stated that the facility probably did an Inservice earlier this week, but she was not present since today is her first day back. RN A stated that since the incident coffee is no longer allowed to be self-served by the residents. Staff has removed the coffee pots. RN A stated that current policy for the facility is if residents want coffee, they need to alert staff to get it ready for them. When asked who is required to check the temperature for coffee pots, she stated she is unsure, that it should be the kitchens duty. In an interview on 05/31/2023 at 10:58 AM, Dinning Supervisor (DS) B stated she was working on the day Resident #17 spilled his coffee on his lap. She stated she was in the satellite kitchen on the first floor. She stated she did not test the temperature of the coffee before placing the coffee out for residents. DS B further stated they did not routinely test the coffee and there was not a policy to test the temperature of the coffee before serving. When asked what the possible outcome of not a policy having to check the Coffee temperature prior to serving to the residents she stated it could result in burns to the residents. Observation on 05/31/2023 at 09:40 AM Resident #17 was observed resting in bed with blankets over the resident. When woken up, Resident #17 stated he is alright just having pain that comes and goes. In an interview on 05/31/2023 10:24 AM Resident #17's FM stated he felt Resident #17 is doing fine now. Resident #17's FM reported his only concern is how a resident like him, confused and weak got 675979 Page 4 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few access to a coffee pot. Resident #17's FM stated that if the facility can remove access for Resident #17 to self-serve his own coffee, then he was fine with facility providing care to him. Observation on 05/31/2023 at 10:30 AM revealed no coffee pots in the dining room that residents could access. Surveyor witnessed coffee pots stored in the kitchen. Observation on 06/01/2023 at 1:41 PM revealed Resident #17 in room in bed. LVN J in room to perform wound care. LVN J removed Resident #17 dressing to left leg to reveal extensive 1st and 2nd degree burns to his left posterior (further back in position; of or nearer the rear or hind end), and anterior (front position) thigh and down his leg extending to his ankle with areas appearing to be 3rd degree (Third-degree burns are a severe burn that reaches the third layer of your skin burns) to his inner left thigh. Continued observation of Resident #17's burns revealed extensive 1st and 2nd degree burns to posterior and anterior right thigh with areas on the inner thigh extending down to his right ankle. In an interview on 06/02/2023 at 9:40 AM the DDS stated that the coffee does come from the main kitchen and the temperature of the machine was set at 200 degrees to go to satellite kitchens. He stated the coffee would lose some heat during transport but was probably served from the satellite kitchens at 175 or 180 or so once it got to the residents. Review of the facility's policy Food and Coffee Safety not dated, provided to Surveyor on 05/31/2023 reflected The community will serve coffee to resident preference. Unless otherwise requested by the resident the coffee will be served between the temp of 160-175 degrees. Coffee service stations will be set up to brew or serve coffee at the designated temperature range . This was determined to be an Immediate Jeopardy (IJ) on 05/31/2023 at 2:40 PM. The Administrator was notified. The Administrator was provided with the IJ template on 05/31/2023 at 3:01 PM. The following Plan of Removal was accepted on 06/01/2023 at 11:57 AM and included: IJ Plan of Removal - Crestview Retirement Community - 05/31/2023 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on May 31, 2023, for failing to ensure hot liquid temperatures are monitored. The 46 residents of the facility had the potential to be affected by this alleged deficient practice. A. Corrective Action: Dining Services staff immediately removed the coffee pots from the dining room areas and therefore eliminated further access for residents to pour their own cup of coffee. A coffee dispenser that has an external digital temperature readout for the internal liquids has been ordered and will arrive on Tuesday, 06/06/2023. Plan for self-serving coffee dispensers will be to serve at a temperature range of 130-150 degrees 675979 Page 5 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Fahrenheit. Temperature range was determined by reviewing published information from the National Institutes of Health - National Library of Medicine for Calculating the optimum temperature for serving hot beverages. Ad Hoc QAPI meeting was held in Administrator's office on 05/31/2023 around 3:15PM with the following in attendance: Administrator, Medical Director, DON, RN Corporate Nurse, Executive Director, AL Director, and Dining Services Director. Community Plan for Removal developed and initiated from this meeting. In-servicing initiated on 05/31/2023 with Dining Services regarding taking and recording temperatures of coffee prior to service. Dining Services staff members will be in-serviced prior to working their next shift and serving residents by the Dining Director and/or designee. In-servicing finished on 05/31/2023. AL Director (Also a current Licensed Nursing Home Administrator) completed the in-servicing with Dining Staff present in the building on 05/31/2023 Administrator in-serviced Dining Director on 05/31/2023. Dining Director in-serviced 11 additional Dining Services staff members via individual telephone calls on 05/31/2023. o Administrator was present in the building on 06/01/2023 prior to breakfast service and verified with two Dining Staff members, that were not present on 05/31/2023, received the phone in-service on 05/31/2023. B. Identification: Nursing department conducted resident hot liquid evaluations on the 46 residents of the facility on 05/31/2023 to determine resident directed interventions, if needed, for individual residents. Interventions put in place on 05/31/2023 to serve coffee at 140 degrees Fahrenheit. Self-service coffee has been temporarily suspended until new coffee dispensers that display the internal temperature of liquids on the outside of the dispenser arrive. Hot liquid evaluations completed on 05/31/203 each resident to determine who is at risk to safely handle hot liquids o On 06/01/2023, facility staff are interviewing residents determined to be at risk to identify individual preferences. The goal of the facility is to serve hot liquids to the preference of the resident while ensuring their safety to handle these liquids. o Resident care plans will be updated to identify resident preference for hot liquids. 675979 Page 6 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0689 C. Level of Harm - Immediate jeopardy to resident health or safety Preventative Measures: Residents Affected - Few Dining Services Servers that work in the SNF satellite kitchens will obtain and record temperatures of hot liquids on a log sheet prior to serving at 140 degrees Fahrenheit at meal times that hot liquids are served. Dining Services will add training regarding hot liquids to new hire orientation for new staff members hired after 05/31/2023 and ongoing to ensure each new staff members are trained on hot liquid safety. Responsible: Dining Services Director and/or on Duty Supervisor Training completed on 05/31/2023 for currently employed staff New staff hired in the future will be trained during orientation starting 05/31/2023 D. Monitoring: Dining Services Director and/or designee will review temperature logs daily for two weeks beginning on 06/01/2023 to ensure compliance. Dining Services Director and/or designee will review temperature logs weekly beginning on 06/15/2023 and report to the community QAPI committee meetings for six months unless otherwise determined by the QAPI committee. Medical Director was present in the building when community was informed of the Immediate Jeopardy on 05/31/2023. Administrator informed Medical Director after community was informed on 05/31/2023. Monitoring for the Plan of Removal was completed from 06/01/2023 through 06/02/2023 as follows Review of the facility's in-service conducted on 05/31/2023 through 06/02/2023 reflected serving hot liquids above 140 degrees has the potential to cause burns in the elderly population. Hot liquids are to be checked and temperature logged prior to serving. Review of the signatures on the in-service reflected all dietary, and dinning staff were in-serviced. Observation on 06/01/2023 and 06/02/2023 revealed no coffee outside of the satellite kitchen on the first or second floor dining room areas. Review of the facility's revised policy provided on 06/01/2023 reflected Safety of Hot liquids, Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition .The potential for burns from hot liquids is considered an ongoing concern among residents .Once risk factors for injury from hot liquids are identified, appropriate resident centered interventions will be implemented to minimize the risk from burns. Such interventions may include (a.) Maintaining a hot liquid serving temperature of not more than 140 degrees Fahrenheit. (b.) serving hot beverages in a cup with a lid .(c.) providing protective lap coving or clothing to protect skin from accidental spills . Review of the Sampled Resident EMRs on 06/01/2023 and 06/02/2023 for Resident #2, 95, 24, 20,19, 11, and 15 reflected all had a Hot liquid evaluations completed. 675979 Page 7 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 06/01/23 at 1:42 PM DA D stated staff are to get the coffee from the main kitchen, check the temperature. DA D stated if the temperature is over 140 F, staff should wait for coffee to cool down to less than 140 F. DA D stated that staff should put up the coffee warmer when the dining is not serving food in the kitchen. DA D stated staff needed to put up coffee heater to prevent residents from being burned. In an interview on 06/01/23 at 1:55 PM DS C stated that the DDS went over training with her yesterday. DS C stated that staff was in services about checking temperature of coffee before being served. DS C stated that if temperature was above 140 F, then staff should re check until it has cool down to less than 140 F. DS C stated, for now, we are to leave the coffee heater behind the counters in the kitchen. DS C stated nurses and/or dining services can only have access to the coffee maker. This is all done to ensure safety for residents and avoid further accidents from happening. In an interview on 06/01/23 at 2:04 PM the DDS stated that before coffee is to be served it must be bought down to 140 or below. They must sign off on the temperature sheet before serving coffee. DDS stated that coffee heater is not accessible to residents anymore because to prevents burns on residents' skin. DDS stated that the facility switched to coffee heaters that are pumps, meaning the cover will not unlock and spill, in case a resident were to get access. Observation and interview on 06/01/23 at 2:15 PM DA G showed surveyor sign in sheet of Coffee Temperature before it is to be served. DA G stated staff are required to log in temperature before serving coffee to residents. She stated temperature must be below 140 F before serving. In an interview on 06/02/2023 at 9:40 AM the DDS stated that the coffee does come from the main kitchen and the temp of the machine is set at 200 degrees to go to satellite kitchens. He stated the coffee would lose some heat but was probably served at 175 or 180 or so once it got to the residents. The DDS stated he in-serviced all staff in dining to ensure the coffee is checked to ensure it is not more than 140 when served to the residents. In an interview on 06/02/2023 at 2:30 PM DA H stated that currently on the floors no coffee can be available for residents to self-serve. DA H quoted We keep the coffee heaters in the back of the kitchen where the residents will not be able to access them. DA H stated staff members are required to take temperature of coffee two times before serving to residents. DA H said that temps are documented immediately upon brewing and another time right before serving when temp is 140 F or below. On 06/02/2023 at 2:30 PM, the Administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. 675979 Page 8 of 9 675979 06/02/2023 Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802

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 store, prepare, distribute, and serve food under sanitary conditions in one of one walk in refrigerator. Residents Affected - Many The facility failed to label and date leftover, opened foods in the walk-in refrigerator in the kitchen. This failure could place the residents at risk of foodborne illness and decreased quality of life. Findings included: In an observation on 05/30/2023 at 10:05 AM in the main kitchen in the walk-in refrigerator revealed an uncovered rolling shelve with meat on metal trays not covered or dated; one full metal tray of barbeque chicken; one full metal tray of baked chicken, on metal tray with a pork tenderloin not covered, dated, or labeled. Further observation revealed a rolling shelve with metal trays with 4 pies on a rack not covered, dated, or labeled. In an interview on 05/30/2023 at 10:08 AM the Chef stated the chicken in the walk-in refrigerator was from the night before and the pork loin was cooked on 05/30/2023 and was cooling to be cut. The Chef stated the meat should be covered, dated, and labeled. He stated not labeling and dating the food could result in food being kept past the date it was safe. The Chef further stated the food not being covered could lead to contamination of the meat from airborne contaminates. The Chef stated the pies should also be dated, labeled, and covered. In an interview on 06/02/2023 at 9:40 AM the Director of Dinning Services (DDS) stated the meat and pies in the walk-in refrigerator should be dated and labeled and covered. The DDS stated failure to do so could lead to contaminated food or expired food being served to residents which could cause food borne illness. In an interview on 06/02/2023 at 11:35 AM the Administrator stated it was his expectation that food in the refrigerator be covered dated and labeled, the Administrator stated, it goes without saying, it is for the safety of the residents. Review of the facility policy Storage of Food and Supplies dated 12/15/2020 reflected .All food non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Cover, label and date .complete all sections on a universal date label .Refrigerated Foods .Cover foods stored on ladder/speed racks to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart or cover each tray individually 675979 Page 9 of 9