Health inspection·October 5, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents have the right to formulate an advanced directive for 4 of 11 residents (Resident #16, #17, #23, and #86) reviewed for advance directives, in that: The facility failed to obtain a valid Out-of-Hospital Do Not Resuscitate (OOHDNR) form for Residents #16, #17, #23 and #86. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having cardiopulmonary resuscitation (CPR) performed against their wishes. The findings were: Record review of the facility's undated document titled admission Agreement revealed a document titled Resident/family consent for cardiopulmonary resuscitation. There was no OOH-DNR document or explanations on how to obtain one found in the agreement. Review of the Resident/Family Consent for Cardio-Pulmonary Resuscitation form , undated, revealed: This Care Center requests that a written signature of the Elder be obtained in advance regarding the desire for cardiopulmonary (CPR) in the event of an extreme emergency. CPR is the initiation of life saving measures for an individual who has had the sudden cessation of cardia and/or respiratory function. These procedures include the artificial respiration (oxygen) and chest compressions. These procedures will artificially enable the heart to keep pumping as well as aerate the lungs. If the Elder is mentally or physically unable to make this decision and the physician documents this, then a Responsible Party can be assigned as durable Power of Attorney for Health Care. Please note that CPR constitutes an extraordinary measure that can be a life saving procedure. Possible effects of these procedures may be some forms of brain damage due to the absence of oxygen reaching the brain. Other side effects can be damage to internal organs or broken ribs. Often these procedures are successful and will allow the patient life saving time until they can make it to the hospital. We ask that you mark ONE of the decisions below, accompanied by your signature and date. If you have further questions, please contact your attending physician. This statement will remain in effect as long as the resident remains a resident of this facility or Page 1 of 15 676015 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0578 until we receive a written and signed notice of revocation from you. Level of Harm - Minimal harm or potential for actual harm (box) I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration, and certain medications for the relief of pain be administered to maintain the resident's comfort. Residents Affected - Some (box) I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency. Resident #16 Review of Resident #16's Face Sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, hypertension (high blood pressure), Diabetes (fluctuating blood sugar), abnormal weight loss, pain, glaucoma, and presence of cardiac pacemaker. The face sheet indicated he was a DNR. Review of Resident #16's Quarterly MDS Assessment, dated [DATE], revealed Resident #16 had: -long- and short-term memory loss and had moderately impaired decision-making skills. - needed assistance of one staff for ADLs, except locomotion and eating which he needed supervision. - used a walker. - was frequently incontinent of bladder and occasionally incontinent of bowel. - was on scheduled pain medication and reported not experiencing any pain; - had two or more falls with no injury; - triggered medications included insulin injections for 7 of 7 days; an antidepressant for 7 of 7 days; and was an anticoagulant for 7 of 7 days. Review of Resident #16's Advanced Directive care plan started [DATE] documented: Need: Resident has the following Advanced Directives on record : Do Not Resuscitate (DNR) *Date of physician's order for DNR ___ Goal: Resident's Advanced Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through next review date. If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Identified Approaches included: discuss advanced Directives with the resident and/or appointed health care representative. An Advanced directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and/or appointed health care representative to provide copies to the facility and any updated Advanced Directives. For DNR Status verify presence of pink DNR on resident's chart, certify presence of physician's order for DNR, place residents name on DNR lists hanging in the facility's common places. 676015 Page 2 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0578 Level of Harm - Minimal harm or potential for actual harm Review of Resident #16's Physician Orders for [DATE] revealed the facility had him coded as a Do Not Resuscitate (DNR). Review of the admission paperwork completed on [DATE] documented the Responsible Party signed the Resident/Family Consent for Cardiopulmonary Resuscitation. Residents Affected - Some Review of Resident #16's admission paperwork showed his primary physician signed the Certificate of Incapacity (facility form) on [DATE]. Interview on [DATE] at 11:55 AM, LVN F stated Resident #16's DNR paperwork should be at the front of chart. She flipped through chart for OOHDNR and was unable to find one. She stated she would ask ADON H if the OOH was not filed yet because they were way behind on the filing. She stated she and the other charge nurse worked with the family forever to get them to make up their mind for the OOHDNR. Interview on [DATE] at 12:04 PM, LVN H stated the family wanted a copy of the OOHDNR and they didn't put it back in the clinical record. She said ADON H was looking for it. Follow-up interview on [DATE] at 9:10 AM, LVN H stated the facility was unable to find Resident #16's OOHDNR so they started a new one yesterday ([DATE]). Interview on [DATE] at 9:29 AM, LVN H stated she and the evening nurse worked months to get the family to accept that Resident #16 was declining and sign the OOHDNR. She stated they convinced the family to go to the social worker. She said she was told the family signed the OOHDNR in the wrong place and the actual OOHDNR was in a folder. LVN H said the OOHDNR did her no good in a folder because if she had to send Resident #16 out she would have been standing there with the Resident/Family Consent for Cardio Pulmonary Resuscitation while the Emergency Medication Technicians waiting on her trying to explain Resident #16 had a OOHDNR. She stated without the OOHDNR the EMTs would not be able to respect Resident #16 wishes. Interview on [DATE] at 10:42 AM, ADON H stated she had more problems with getting the OOHDNR than anything. She said in Resident #16's case the Responsible Party signed the form in the wrong place. ADON H stated she did not know why the social worker did not catch the error. Resident #17 Review of Resident #17's Face Sheet, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, restlessness and agitation, hypertension, chronic pain, and need for assistance with personal care. Her Face Sheet indicated she was a DNR. Review of Resident #17's Care Plan dated [DATE] revealed, in part, Elder has a terminal illness with a prognosis of six months or less; place copy of advanced directive on the chart, For DNR status: verify presence of PINK DNR on resident's chart, verify presence of physicians order for DNR, place resident's name on DNR lists hanging in the facility common places. Review of Resident #17's Quarterly MDS assessment, dated [DATE], revealed: Her cognitive status was not assessed. 676015 Page 3 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0578 She had no symptoms of delirium. Level of Harm - Minimal harm or potential for actual harm She sometimes understood others and sometimes was understood. She had unclear speech. Residents Affected - Some She had physical behaviors 1 to 3 out of 7 days. She had verbal behaviors 1 to 3 out of 7 days. She had other behaviors 4 to 6 out of 7 days. She required extensive assistance with most ADLs, was totally dependent for bathing, and required limited assistance with eating. She used a wheelchair for locomotion. She was always incontinent of bowel and bladder. She had a condition or chronic disease that might result in a life expectancy of less than 6 months. She received antianxiety medication 7 out of 7 days. Review of Resident #17's clinical record revealed no OOHDNR. Resident #23 Review of Resident #23's Face Sheet, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, hypertension, anxiety disorder, hypokalemia (low potassium), insomnia, chronic kidney disease, Type 2 diabetes mellitus, and pain. His Face Sheet indicated he was a DNR. Review of Resident #23's Care Plan dated [DATE], revealed, in part, DNR; For DNR status: verify presence of PINK DNR on resident's chart, verify presence of physicians order for DNR, place resident's name on DNR lists hanging in the facility common places. Review of Resident #23's Quarterly MDS assessment, dated [DATE], revealed: He scored a 3 out of 15 on his mental status exam (indicating severe cognitive impairment). He exhibited physical behavioral symptoms directed at others 1 to 3 of 7 days. He refused care 1 to 3 of 7 days. He had wandering behavior 4 to 6 of 7 days. He required extensive assistance with dressing, toileting, and personal hygiene. He required one person assistance for all other ADLs. 676015 Page 4 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0578 He used a rolling walker to ambulate. Level of Harm - Minimal harm or potential for actual harm He was frequently incontinent of bladder and always incontinent of bowel. He received antianxiety medication 7 of 7 days. Residents Affected - Some Review of Resident #23's clinical record revealed no OOHDNR. Resident #86 Review of Resident #86's Face Sheet, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, urinary tract infections, pain, psychotic disorder with hallucinations, anxiety, hypertension, and neuropathy. The face sheet identified she was on hospice and was a DNR. Review of Resident #86's Physician's Orders for [DATE] revealed she was on hospice and was identified as a Do Not Resuscitate. Resident #86's admission MDS assessment, dated [DATE], revealed Cognitive ability was not assessed. She was totally dependent on one or two staff for all ADL's. She used a wheelchair. She had a catheter. Pain was not assessed. She was identified as having less than 6 months to live. Triggering medications included an antipsychotic for 7 of 7 days, an antianxiety medication for 6 of 7 days, an antidepressant for 7 of 7 days, and antibiotic for 7 of 7 days. Review of Resident #86 care plan documented a care plan for a DNR that included approaches that included Date of Physician Order for DNR __ Interview on [DATE] at 12:58 p.m., ADON H looked through Resident #86's clinical record and confirmed she did not have an OOHDNR. She stated Resident #86 was admitted to the facility two weeks ago. ADON H stated the Hospice company stated they would get one so she guessed Resident #86 was a full code on hospice for about a year prior to her admission. Interview on [DATE] at 12:13 p.m., the Administrator said the facility used the Resident/Family Consent for Cardiopulmonary Resuscitation in place of a DNR. She stated the form covered the facility for what happened in the facility but would not cover the facility if they needed to send a resident to the emergency room or something. Interview on [DATE] at 12:27 p.m., LVN F said she was not comfortable with the Family Consent for Cardio-Pulmonary Resuscitation. She said in the event of finding a resident not breathing she would send the resident out to the ER. She said she worked with a family for two months to sign a OOHDNR 676015 Page 5 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because she was not comfortable with that form. LVN F said as a nurse she would not accept the consent form in place of an OOHDNR. She said she did not know the facility's policy for DNRs and had not received any in-services about it because we know as a nurse. Interview on [DATE] at 12:58 p.m., ADON H stated the family consent was what the facility used. She said as a nurse working the floor, if that was all the resident had they had to send the resident to the emergency room and treat them as a full code. She said unless the resident signed the OOHDNR on admission, they facility would have to send out the OOHDNR to be signed by the doctor. ADON H stated she did not know how long the process took because she did not keep up with it. ADON H stated surveyor would have to ask the DON what the policy was and how long the process should take. She said the social worker was responsible for keeping up with the OOHDNR but the facility was between social workers right now and had a designee. She said they had been without one for at least six months. Interview on [DATE] at 1:41 p.m., the SSD stated she was designated to be the SSD until the facility found a full-time social worker. She stated she did a lot of OOHDNR on the rehab side of the facility but had not been doing much on the long-term side unless the facility brought it to her attention. The SSD said she did not check to see if a resident's code status was consistent through all the lists and records. She stated one doctor came about once a week and that was when he would sign the OOHDNR. She said there was not an initial timeframe for how long it took to get it signed, it just depended on the doctor. She said the facility had a cheat sheet for who was what code status, and she went by the in-house list. The SSD said she would not have any idea how many residents an OOHDRN had signed because she did not check them. She said the only list she checked was on the rehab side. Interview on [DATE] at 2:36 PM, the DON said the facility went through on admission and asked family what their advanced directive was at that time. She said as a nurse working the floor, she would be comfortable accepting the Family Consent form in place of an OOHDNR. The DON stated the facility had not trained nurses on OOHDNRs. She said the nurses had multiple places to check for code status including the crash cart, the pink or yellow sheet at the front of the resident's file, the physician's order and/or face sheet on the computer, on the 24-hour report. She stated the consent was only in-house and an OOHDNR would go with the EMT. She said if it came down to brass tacks the EMTs would have to perform CPR on the resident. The DON said the facility had no policy on DNR/CPR. She said she had not in-serviced the nurses because as nurses they all know. The DON said she checked approximately a month ago to make sure the code lists were consistently documented 676015 Page 6 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0679 Provide activities to meet all resident's needs. 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 provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests, and the physical, mental, and psychosocial well-being of 5 of 6 residents reviewed for activities. (Residents #7, #19, #20, #23, and #86). Residents Affected - Some Residents on the Younger Unit were not provided with activities that matched the cognitive or psychosocial level for Residents #7, #19, #20, #23, and #86. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: Resident #7 Review of Resident #7's Face Sheet dated 10/05/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbances, heart disease, hypertension, hypothyroidism (low thyroid), major depressive disorder, anxiety disorder, hypokalemia (low potassium), hyperlipidemia (high cholesterol), insomnia, and chronic pain. Review of Resident #7's Quarterly MDS assessment, dated 6/20/22, revealed: She scored a 0 out of 15 on her mental status exam (indicating severe cognitive impairment). She exhibited wandering behaviors 4 to 6 of 7 days. She needed extensive to total assistance for all ADLs but was able to feed herself with only setup assistance. She was always incontinent of bowel and bladder. She used a wheelchair for locomotion. She received antipsychotic medication 7 of 7 days. She received antianxiety medication 7 of 7 days. She received antidepressant medication 7 of 7 days. Activities were not addressed. Resident #19 Review of Resident #19's Face Sheet, dated 10/5/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disorder, hypertension, pain, abnormal weight loss, mood disorder (mild depression), convulsions, hyperlipidemia (high cholesterol), and anxiety. The face sheet indicated she was [NAME] Catholic. 676015 Page 7 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0679 Review of Resident #19's Quarterly MDS assessment, dated 8/17/22, revealed: Level of Harm - Minimal harm or potential for actual harm Cognitive abilities/Mental Status Exam was not assessed. She showed no signs of delirium. Residents Affected - Some She needed supervision of staff for transfers, walking and eating. She needed assistance of one staff for all other ADLs. She was frequently incontinent of bladder and continent of bowel. She had no pain and no falls. Trigger medications was an antidepressant for 7 of 7 days. Review of Resident #19's Annual MDS assessment, dated 5/17/22, revealed: She had long- and short-term memory impairment with modified independent decision-making skills. It was very important to the resident to listen to her preferred music, to do things with groups of people, to do her favorite activities, to go outside, and to participate in religious activities. Resident #20 Review of Resident #20's Face Sheet, dated 10/5/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, above the knee amputation, hyperlipidemia, blindness in the left eye, arthritis, depression, pain, neuropathy (nerve pain), anxiety, and mood disorder. Review of Resident #20's Quarterly MDS Assessment, dated 8/17/22, revealed: She scored a 5 of 15 on her mental status exam (indicating severe cognitive impairment). She needed assistance of one staff for all ADLs. She used a wheelchair. She was frequently incontinent of bowel and bladder. She had no pain and no falls. Triggering medications included an antidepressant for 7 of 7 days and an anxiety for 7 of 7 days. Review of Resident #20's Annual MDS Assessment, dated 7/7/22, revealed it was very important for her to listen to her preferred music, to do her favorite activities, and participate in religious practices. Resident #23 676015 Page 8 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0679 Level of Harm - Minimal harm or potential for actual harm Review of Resident #23's Face Sheet, dated 10/05/22, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, hypertension, anxiety disorder, hypokalemia (low potassium), insomnia, Type 2 diabetes mellitus, and pain. Review of Resident #23's Quarterly MDS assessment, dated 8/22/22, revealed: Residents Affected - Some He scored a 3 out of 15 on his mental status exam (indicating severe cognitive impairment). He exhibited physical behavioral symptoms directed at others 1 to 3 of 7 days. He refused care 1 to 3 of 7 days. He had wandering behavior 4 to 6 of 7 days. He required extensive assistance with dressing, toileting, and personal hygiene. He required one person assistance for all other ADLs. He used a rolling walker to ambulate. He was frequently incontinent of bladder and always incontinent of bowel. He received antianxiety medication 7 of 7 days. Activities were not addressed. Resident #86 Review of Resident #86's Face Sheet, dated 10/5/22, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, urinary tract infections, pain, psychotic disorder with hallucinations, anxiety, hypertension, and neuropathy. Resident #86's admission MDS assessment, dated 9/27/22, revealed Cognitive ability was not assessed. She was totally dependent on one or two staff for all ADL's. She used a wheelchair. She had a catheter. Pain was not assessed. She was identified as having less than 6 months to live. Triggering medications included an antipsychotic for 7 of 7 days, an antianxiety medication for 6 of 7 days, an antidepressant for 7 of 7 days, and antibiotic for 7 of 7 days. Observations on the Younger Unit 10/3/22 at 10:51 a.m. through 12:35 p.m., showed no activities occurred. The noon meal was observed from 11:43 a.m. - 12:35 p.m., the staff were observed passing food but there were no other resident interaction, there was no music playing and there was nothing to 676015 Page 9 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some do. At 12:00 p.m. the residents who were able to eat independently were getting restless and were playing with the cloth items in reach (clothes protector, napkins) by folding them; the independently mobile residents began to try to wander off and the dependent residents had increase hand wringing or other repetitive motions. At 12:11 p.m. Resident #26 (non-sampled) started yelling out can we go now, when staff tried to correct her she responded well, lets go!. Resident #8 (not sampled) pushed herself backwards with her feet repetitively trying to tip her wheelchair over. At 12:19 p.m. Resident #7 (not sampled) started sorting her silverware and licking her butterknife. Staff snatched it out of her hands telling her she could not have the butterknife but could have the fork and spoon. When Resident #7's table mate was served lunch, she immediately started to reach over to grab it. Observation on the Younger Unit on 10/5/22 between 9:08 a.m. and 10:48 a.m., showed no activates occurring on the unit. After the morning meal, residents were parked in front of the television and left to sit there. Observation of the [NAME] unit during the same time revealed the residents were getting manicures outside). Observation on 10/5/22 between 12:44 p.m. and 2:00 p.m. showed no activities on the Younger Unit. Interview on 10/05/22 at 1:35 PM, LVN F stated there were no scheduled activities for the Younger Unit. She stated sometimes they had eating popcorn as a group activity and there was bible study on Thursday nights, but generally there was nothing else offered. She stated the staff normally parked the residents in front of the television and left them. LVN F stated the residents on the Younger Unit were viewed as though they weren't missing out by not having activities due to their cognitive statuses. She stated she believed the lack of activities was due to budget and the facility not having enough staff. Interview on 10/05/22 at 2:53 PM, the DON stated the Younger Unit had an activity calendar. She stated there was a staffing issue right now and the facility was trying to fill the scheduling holes right now. She said the CNA Coordinator was usually responsible for doing activities on the Younger Unit but was working the floor as a CNA that week. The Administrator said the unit did a lot of music and memory activities and the residents liked it. They both said the activities did not get done every day. The DON stated the facility had a Chaplain that did a bible study with the residents and if he was unavailable, then Resident #23 used to be a minister and he would do it. The Administrator stated that the CNAs would do circles with the residents which was when the staff would sit around and talk with the residents about an event. The Administrator added visitors would come and do impromptu stuff with the residents like play music. The Administrator and DON agreed it had not been a good week for Activities on the Younger Unit due to staffing. The DON stated the residents would sometimes play with baby dolls and on the weekends, they did a movie with a projector with movie type of snacks. The DON said when the CNA Coordinator could be at the facility during the day activities would usually get done, but she was currently working on the rehab unit . Observation and interview on 10/05/22 at 3:10 PM, revealed CNA G playing music and interacting with 9 residents in the dining room. CNA G stated they had music and dancing every day around 3PM when they could. She stated that the residents liked music and didn't like having to leave the unit or go outside because they got anxious. She stated she was a neighborhood coordinator but had been working in the kitchen and on the floor because facility had been short staffed. Interview on 10/05/22 at 4:04 PM, the Activity Director stated she believed there were activities happening on the Younger Unit but there were not as many as there could have been because the campus had large scale outdoor activities planned for the week and the residents on Younger Unit would not 676015 Page 10 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have enjoyed attending them. She stated that each unit was supposed to have a neighborhood coordinator that was responsible for planning activities for each unit, but that currently there was not enough staff to accommodate it. The Activity Director stated the neighborhood coordinator for the Younger Unit was working in the kitchen and as direct care due to staff shortages. She stated she would have to look at the activity calendar for the Younger Unit to see what changes could be made in the future. She stated that she was unaware there were not activities for the residents in the mornings in the Younger Unit. Interview on 10/05/22 at 6:00 PM, the DON stated the facility did not have a policy regarding activities. She stated all staff received training online related to activities for residents with the diagnosis of Alzheimer's/dementia. 676015 Page 11 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

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 to help prevent the development and transmission of communicable diseases and infections for 4 of 8 (Resident #2, #189, #191 and #195) reviewed for infection control in that: Residents Affected - Some a) Resident # 189's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. b) Resident # 191's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. c) Resident # 195's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. d) CNA A wiped Resident #2's vaginal area with back to front motion and then applied her brief while wearing soiled gloves. This failure could place residents at risk of respiratory infections, cross contamination and spread of infections. Findings included: INCONTINENT CARE: Record review of Resident #2's admission record dated 05/12/22 indicated she was admitted to the facility on [DATE] with diagnoses of osteoarthritis (joint disease) and pain. She was [AGE] years of age. Record review of Resident #2's MDS dated [DATE] indicated in part: Cognitive Patterns - Cognitive skills of daily decision making = moderately impaired- decisions poor; cues/supervision required. Bladder and Bowel: Urinary Continence =. e. Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #2's care plan dated 10/04/22 indicated in part: Problem/Need: Incontinent of bowel and bladder. Goal and target date: Will be clean, dry and comfortable in between incontinent episodes over the next 90 days. Approaches: Administer peri-care after each incontinent episode. 676015 Page 12 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0880 Level of Harm - Minimal harm or potential for actual harm During an observation on 10/03/22 at 11:29 AM, CNA A performed incontinent care for Resident #2. CNA A took some wet wipes and wiped the residents vaginal area a couple of times with a back to front wiping motion. The resident was turned on her right side and the CNA proceeded to clean the residents rectum. The resident had a bowel movement also. While still wearing the same gloves CNA A proceeded to apply the new brief on the resident. Residents Affected - Some During an interview on 10/05/2022 at 12:48 PM, CNA A said the way to wipe the resident's peri-area was with a front to back motion. CNA A said during incontinent care with Resident #2 she had become very nervous and wiped in the wrong direction which was back to front. CNA A said she knew she was supposed to change her gloves prior to applying the clean brief. CNA A said she was so nervous she forgot to change them prior to applying the new brief on the resident. CNA A said wiping from back to front could lead to UTI's and not changing her gloves could lead to cross contamination. CNA A said she received training on those tasks regularly. During a telephone interview on 10/05/22 at 09:46 AM, the nurse aide instructor said she did skills training with skills with the CNAs such as how to wash their hands, glove changing and discuss how to wipe the residents during incontinent care. The instructor said they monitored the CNAs by conducting in-services. The instructor said she was responsible for training the staff on incontinent care and infection control procedures. The instructor said when CNAs performed incontinent care they were supposed to wipe away from the urethra and to wipe from front to back. The instructor said if the staff wiped from back to front that could lead to a risk of infections such as a UTIs. The instructor said staff were trained to change their gloves after they performed the incontinent care and when going from dirty to clean. The instructor said the staff were supposed to don new gloves to place the new brief on the resident to prevent cross contamination. The nurse aide instructor said she believed the failure occurred because the nurse aide got nervous and forgot her steps. During an interview on 10/05/22 at 04:56 PM, the Administrator and DON said the nurse aide instructor would do in-services with CNAs regarding incontinent care and that the DON would also do trainings. The DON said the aides were supposed to wipe from front to back so the residents would not get UTIs. The DON said the aides were supposed to change their gloves when going from dirty to clean to prevent cross contamination. The DON and Administrator said they believed the failure occurred because the CNA got nervous and forgot the correct steps. NASAL CANNULA TUBING: Record review of Resident # 189's face sheet revealed admission date of 10/01/2022 with diagnoses of pseudoaneurysm (blood vessel wall is injured and the leaking blood collects in the surrounding tissue), left basilar atelectasis (partial collapse of your lungs), acute hypoxemia respiratory failure (you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal). The resident was [AGE] years of age. Record review of Resident #189's care plan dated 10/01/2022 indicated, in part: Interventions: oxygen 1 Liter per minute via nasal cannula, as needed. Record review of Resident #189's medication profile dated 10/01/2022 indicated in part: Oxygen via nasal cannula at 1 liter per minute, as needed. Record review of Resident #191's face sheet revealed admission date of 09/28/2022 with diagnoses of 676015 Page 13 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0880 Level of Harm - Minimal harm or potential for actual harm Congestive Heart Failure (heart muscle doesn't pump blood as well as it should), hypoxemia (abnormally low concentration of oxygen in the blood), Acute Upper Respiratory Infection, Cough. She was [AGE] years of age. Record review of Resident #191's medication profile dated 09/28/2022 indicated in part: Residents Affected - Some Oxygen 1 liter per minute via nasal cannula, as needed. Record review of Resident # 195's face sheet revealed admission date of 09/30/2022 with diagnoses of Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). She was [AGE] years of age. Record review of Resident #195's care plan dated 09/30/2022 indicated, in part: Interventions: oxygen via nasal cannula, as needed, 2 liters per minute for COPD. Record review of Resident #189's medication profile dated 09/30/2022 indicated in part: Oxygen 2 liters per minute via nasal cannula, as needed. During an observation on 10/3/22, 10/4/22 and 10/5/22 Resident #195's oxygen tubing was not in plastic bag when not in use. During an interview and observation on 10/05/2022 at 09:55 AM, Resident #195's oxygen tubing revealed the cannula and tubing hanging on the recliner and nebulizer mask on bedside table while not being used. Resident #195 was in the wheelchair, oxygen tank attached to wheelchair and oxygen tubing and cannula hanging on oxygen tank. There were no plastic bags to store oxygen tubing, cannula and mask while not in use. CNA E stated that oxygen tubing is supposed to be in a clear plastic bag when not in use. CNA E stated she would get plastic bags to bag them all up. During an observation on 10/3/22, 10/4/22 and 10/5/22 Resident #189's oxygen tubing was not in a plastic bag when not in use. During an interview on 10/05/2022 at 09:40AM, revealed Resident #189's oxygen tubing and cannula lying on an unmade bed. The wheelchair in the resident's room revealed the oxygen tubing and cannula in the wheelchair seat while not in use. No plastic bags to store the oxygen tubing and cannula were observed while they were not in use. During observations on 10/3/22, 10/4/22 and 10/5/22 Resident #191's oxygen tubing was not stored in plastic bag when not in use. During an interview and observation on 10/05/22 at 09:45AM, Resident #191's oxygen tubing and cannula was hanging from oxygen concentrator and not in use. There was no plastic bag in the room to store oxygen tubing and cannula and mask while they were not in use. During an interview on 10/05/2022 at 10:08 AM, LVN D stated that all residents with oxygen should have plastic bags for the oxygen tubing when not in use. LVN D stated when residents are admitted to the facility with oxygen ordered, staff should place a plastic bag in the room for storing the oxygen tubing when it is not being used. LVN D stated that she will get bags for the residents now. 676015 Page 14 of 15 676015 10/05/2022 Mabee Health Care Center 2208 N Loop 250 W Midland, TX 79707

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/05/2022 at 11:30 AM, the DON stated the facility had no policies for oxygen tubing storage and she was aware of Residents #189, #191, and #195 not having storage bags for oxygen tubing this morning but stated it has been fixed now. Record review of the facility's document titled Infection control-personal protective equipment and dated 3/15/2020 indicated in part: Facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors and other staff. Gloves: wear gloves when direct contact with blood, body fluids, mucous membrane, non-intact skin, or potentially contaminated surfaces or equipment is anticipated. 676015 Page 15 of 15