Health inspection·June 16, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm 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, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #16) of 16 residents reviewed for supervision and assistive devices. The facility failed to ensure Resident #16, with a known history of falls, had bolsters on his bed as well as fall mats on each side of his bed as ordered by his physician. This failure could place residents at risk of not receiving the appropriate level of assistance and supervision with the potential for falls and/or injuries. Findings included: Review of the undated face sheet for Resident #16 revealed an [AGE] year-old male with an admission date of 01/19/18 and diagnoses to include difficulty in walking, Alzheimer's disease, muscle weakness, and history of falling. Review of the MDS for Resident #16, dated 04/27/22, revealed he required extensive assistance in bed mobility, dressing, toilet use, and personal hygiene. Resident #16 had active diagnoses of difficulty in walking, muscle weakness, and history of falling. The MDS also revealed Resident #16 was always incontinent of both bowel and bladder. Review of the undated care plan for Resident #16 revealed a focus area of Resident #16 is at risk for falls and injuries related to decreased mobility and history of falls with an intervention of fall mats on both side of resident's bed initiated on 04/02/20. Review of the undated Order Summary Report for Resident #16 revealed an order on 05/26/22 of bolster to bed to help prevent frequent falls, and an order on 09/13/21 for fall mats in place for safety at all times when resident is in bed, check every shift for safety. Observation on 06/14/22 at 11:15 a.m. revealed Resident #16 was resting in bed watching tv without a fall mat on the resident's left side of the bed and no bolsters on the bed. Observation and interview on 06/14/22 at 5:12 p.m. revealed Resident #16 was resting in bed watching tv without a fall mat on the resident's left side of the bed and no bolsters on the bed. The ADON pointed out that the bolsters were stacked by the dresser and stated she was going to put them back on immediately. She stated they were most likely taken off to change the bed linens and not put back Page 1 of 7 676009 676009 06/16/2022 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on. The ADON stated she believed Resident #16 was only ordered a fall mat for one side of his bed, but she would look into it. Interview on 06/15/22 at 2:45 p.m. LVN A stated the expectation was the bolsters were to be on Resident #16's bed as the physician ordered. She stated the bolsters may have been taken off the bed when they transferred the resident and did not get put back on. LVN A stated the risk to the resident was more falls. Interview on 06/15/22 at 8:52 a.m. the DON and ADON stated the expectation was care plans and physician orders always be followed by the nursing staff and were available to the nursing staff. The ADON stated she was not sure why one of the fall mats disappeared and Resident #16 normally did have two fall mats. The ADON stated she immediately replaced the missing floor mat next to Resident #16's bed and started in-servicing staff. The ADON also stated she contacted the bolster medical equipment company to provide training to the staff on using the bolsters on the resident's bed. The ADON and DON stated the risk to the resident in not having the bolsters and a fall mat was injury, reduced quality of life, and continued falls. Review of the facility's Care Planning policy, dated August 2006, revealed The Interdisciplinary Team will review the Attending Physician's order and implement a nursing care plan to meet the resident's immediate needs. Review of the facility's Bed Safety policy and Accident and Incidents Policy revealed they did not address fall prevention measures. 676009 Page 2 of 7 676009 06/16/2022 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure sanitary practices were maintained in the kitchen as frozen foods were improperly stored, and freezers and refrigerators were unsanitary. These failures could place residents who ate from the kitchen at risk for cross-contamination and food-borne illness. Findings included: Observation on 06/14/22 at 10:20 a.m. revealed in the outside walk-in freezer there were uncovered and exposed hamburger patties. There was also beer battered onion rings that were soft to the touch and not completely frozen. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated the expectation was the hamburger patties be in a closed bag and the onion rings thrown out. She stated an employee had accessed the hamburger patties and did not close the bag. She also stated the onion rings were close to the door of the freezer which was why they had thawed out. The Dining Room Manager stated there was no risk to the residents as neither the hamburger patties nor the onion rings would had been used but thrown away. Review of the facility's undated Food Storage Guidelines policy revealed Opened ingredients should be stored in sealed, airtight containers, and Doors to all cold storage facilities should be kept closed when not in use. Review of the U.S. Public Health Service, Food Code (2017) section § 3-302.11 (A)(6) revealed, FOOD shall be protected from cross contamination by: Protecting FOOD containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. Review of the U.S. Public Health Service, Food Code (2017) section § 3-501.11 revealed, Stored frozen FOODS shall be maintained frozen. Observation on 06/14/22 at 10:20 a.m. revealed the outside walk-in freezer floor had debris, spillage, and food crumbs. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated the expectation was the freezer was to be cleaned every night and that the evening supervisors survey the kitchen to ensure proper cleaning. She thought the outside freezer got missed the previous evening. She stated there was no risk to the residents as that day she had the freezer cleaned. Review of the facility's undated Food Storage Guidelines policy revealed, Cold (both refrigerated and freezer) storage areas should be clean and free from moisture or ice build up. Review of the U.S. Public Health Service, Food Code (2017) section § 4-601.11(C), 676009 Page 3 of 7 676009 06/16/2022 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Interview on 06/16/22 at 9:15 a.m. the surveyor requested a cleaning schedule, the Dining Room Manager stated they did not have one. Residents Affected - Many Observation on 06/14/22 at 10:20 a.m. revealed the ice cream freezer had a thick layer of ice at the bottom. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated the ice cream freezer needed to be defrosted and cleaned out. She stated this was completed once a month. She also stated the reason there was a layer of ice was someone may have halfway cracked the freezer door and caused the water to defrost and freeze on the bottom. The Dining Room Manager stated there was not a risk to the residents as she checked the temperature and if it was incorrect everything was thrown out. Review of the facility's undated Food Storage Guidelines policy revealed, Cold (both refrigerated and freezer) storage areas should be clean and free from moisture or ice build up. Review of the U.S. Public Health Service, Food Code (2017) section §4-602.13 revealed, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Observation on 06/14/22 at 10:20 a.m. revealed the meat walk-in refrigerator and the produce walk-in refrigerator fans had dark gray debris and dust build-up. Interview on 06/16/22 at 9:15 a.m. the Dining Room Manager stated a company comes out once a month and services their freezers; she stated the company had not yet been out to clean this month. She also stated the risk to the residents was dust could get on the produce, but it was washed prior to preparing. Review of the facility's undated Food Storage Guidelines policy revealed, Cold (both refrigerated and freezer) storage areas should be clean and free from moisture or ice build up. Review of the U.S. Public Health Service, Food Code (2017) section § 4-601.11(C), NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 676009 Page 4 of 7 676009 06/16/2022 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient and physician certification specific to each patient, for 1 of 3 residents (Resident #1) reviewed for hospice services. The facility failed to obtain Resident #1's current Hospice physician re-certification of the terminal illness and a current Hospice plan of care from Hospice. These failures could affect residents by placing them at risk for services and treatments not being coordinated for end-of-life care. Findings included: Review of Resident # 1's face sheet dated 06/16/22 revealed Resident # 1 was admitted on [DATE] and readmitted on [DATE] to the facility with a diagnosis of fracture of left femur, retention of urine, and orthopedic aftercare. Review of Resident #1's physician orders reflected she was admitted to the facility on [DATE] under hospice care. Review of Resident # 1's clinical record reflected the facility did not have a hospice book for her. There were no hospice physician certification of the terminal illness nor a hospice plan of care. In an interview on 06/14/22 at 3:34 pm with the Nurse Manager revealed Resident # 1 was readmitted to the facility on [DATE] on hospice due to end of life. The Nurse Manager was unable to locate the resident's hospice binder. The Nurse Manger stated she would look for the binder and provide it once it was located. In an interview on 06/15/22 at 10:57 am with the Nurse Manager revealed she was unable to located Resident #1 Hospice binder. In an interview on 06/15/22 at 3:12 pm with the ADON and DON, revealed they were unable to locate Resident #1's hospice records and it had been requested from the hospice agency. The ADON and DON stated the care plan developed by the facility was the same care plan the hospice agency would use. They were unaware of where to locate the physician certification of terminal illness. The DON revealed she was the facility's designated person to coordinate hospice services. In an interview on 06/15/22 at 4:00 pm with Resident # 1's Hospice Registered Nurse revealed the hospice agency would develop their own plan of care for the resident, and it may or may not coincide with the facility's. Record Review of the facility's End of Life policy titled Hospice Program revised July 2017 reflected the facility's designee .is responsible for the following: (d) obtaining the following information from the hospice: (1) the most recent hospice plan of care specific to each resident, (3), physician certification and recertification of the terminal illness specific to each resident. 676009 Page 5 of 7 676009 06/16/2022 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

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 to prevent the development and transmission of communicable diseases for 2 (MA B, and MA C) of 2 staff and for (Resident #19, and #21) of observed for infection control. Residents Affected - Some 1. MA B failed to perform hand hygiene for Resident's #21 during eye drop administration. 2. MA C failed to perform hand hygiene for Resident #19 during eye drop administration. 3. LVN E failed to change a contaminated nasal cannula tubing prior to placing it back into Resident #1's nose after it was observed on the floor. These failures could place residents at risk for spread of infection. Findings included: 1. Review of Resident #21's Face Sheet dated 08/06/2021 reflected she was a [AGE] year-old female admitted to the facility on [DATE].Her diagnoses included Glaucoma and Diabetes. Review of Resident #21's Physician orders dated March 22 reflected, Dorzolamide-Timolol (ophthalmic solution) 2% one drop in left eye three times a day for Glaucoma. An observation on 06/14/22 at 1:18 p.m. revealed MA C pulled the medication cart to Resident #21's room. She opened the medication top drawer, obtained a bottle of Dorzolamide-Timolol, then closed the drawer and pulled one Kleenex for a box. She entered Resident#21's room without washing her hands. She explained to the resident it was time for her eye drops. She proceeded to the bedside, removed the cap from the bottle of Dorzolamide-Timolol then pulled down the lower eye lid with her left hand without performing hand hygiene and applied one drop of Dorzolamide-Timolol solution into the sac of the left eye and handed the resident the Kleenex, then exited the room without washing her hands. An interview with MA C on 06/14/22 at 12:50 p.m. revealed she should have performed hand hygiene and used gloves for eye drop administration. She said she should have washed her hands before she put on her gloves and after she removed her gloves. She stated she was just not thinking. 2. Review of Resident #19's Face sheet, dated 10/28/2021 reflected he was a [AGE] year-old male with an admission date of 10/28/2021. His diagnoses included Glaucoma and Hypertension. Review of Resident #19's Physician orders dated March 022 reflected, Timolol (ophthalmic solution) 0.25% one drop in both eye two times a day for Glaucoma. An observation on 06/14/22 at 3:07 p.m. revealed MA D pushed the medication cart to Resident #19's room. He opened the medication top drawer obtained a bottle of Timolol Ophthalmic solution, then closed the drawer. He entered Resident#19's room without washing his hands. He explained to the resident it was time for his eye drops. He proceeded to the bedside, removed the cap from the bottle of Timolol, reached over on the bedside table, pulled a tissue from the box without washing his hands he 676009 Page 6 of 7 676009 06/16/2022 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pulled down the lower right eye lid with his right index finger, applied one drop of Timolol solution into the sac of the right eye, then he pulled down the left lower eye lid with his right index finger applied one drop of Timolol solution into the sac of the left eye without performing hand hygiene. Then he handed the resident the tissue paper and exited the room without washing his hands. In an interview with MA D on 06/14/22 at 3:55 p.m. revealed he was supposed to wash his hands between each resident and before applying eye drops to the resident's eyes. He stated he realized he should have washed his hands and used gloves before applying eye drops. He stated he was a little nervous. An interview with the ADON on 06/15/22 at 10:35AM she revealed that hand washing was expected for eye drop administration. She stated staff was to perform hand hygiene and glove changes before and after eye drop administration. Review of the facility's dated August 2019 policy titled Handwashing, reflected, . All personnel shall follow the handwashing/hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors soap and water for the following situations before and after contact with residents .after contact with resident's intact skin. 3. Record Review of Resident #1's face sheet dated 06/16/22 reflected the resident was a [AGE] year-old female, initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of congestive heart failure and chronic obstructive pulmonary disease. Observation of Resident #1 on 06/15/22 at 11:02 revealed resident's nasal cannula was on the floor under the bed. Observation and interview of LVN E on 06/15/22 at 11:06 revealed she picked up Resident #1's nasal cannula tubing from the resident's bedroom floor and placed it in Resident #1's nose. Interview with LVN E directly following the observation reflected she should not have placed the nasal cannula into the resident's nose, because it was contaminated with possible bacteria from being on the floor, which could lead to infection. LVN E apologized and stated she should have gone to her medication cart and retrieved new tubing. 676009 Page 7 of 7