Health inspection·June 8, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 accommodate residents needs and preferences and accommodation of needs, for 2 (Resident #2, Resident #5) of 5 residents reviewed for dignity. Residents Affected - Some The facility failed to ensure Resident #2 and Resident #5 call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Review of Resident #2's face sheet dated 06/08/2023 revealed a [AGE] year-old female admitted on [DATE] with following diagnosis: Dementia, Anxiety disorder, Major Depressive disorder, Psychotic Disorder with Delusions and Alzheimer's. Review of Resident #2's MDS dated [DATE] revealed: Section C -Cognitive Patterns BIMS score of 00, which indicated she had severe cognitive impairment). Section F: Functional Status revealed Resident #2 required extensive assistance with transfers and when out of bed did not ambulate on her on was in wheelchair. Review of Resident #2's most recent Care plan reviewed on 06/08/2023 revealed: Be sure her call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. Review of Resident #5's face sheet revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Type 2 Diabetes, history of stroke, pressure ulcer of left buttocks, and Atrial Fibrillation (abnormal heart rhythm). Review of Resident #5's Quarterly MDS dated [DATE] revealed Section C: Cognitive Patterns revealed a BIMS score of 9, which indicated her cognition was moderately impaired; Section F:Functional Status revealed Resident #5 required extensive assistance with transfers and when out of bed did not ambulate on her on was in wheelchair. Review of Resident #5's most recent care plan reviewed on 06/08/2023 revealed, Be sure her call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. Observation on 06/05/23 at 03:53 PM revealed Resident #2 was sitting in her recliner in her room Page 1 of 16 676053 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0558 Level of Harm - Minimal harm or potential for actual harm and the call light was not attached to Resident #2's recliner, call light was laying on bedside table where resident was not able to reach. Observation on 06/06/23 at 3:16 PM revealed Resident #5 lying in her bed and the call light was lying in the floor behind the bed. Residents Affected - Some During an interview on 06/06/23 at 3:21 PM the DON stated her expectation was call lights should have been answered in less than 3 minutes and call lights should be placed within reach. The DON stated call lights should not have been on the floor. During an interview on 06/06/23 at 3:24 PM NA H stated the call light should have been placed within reach, so the resident could have pulled it if needed. NA H stated residents not having access to call light could have resulted in the resident receiving an injury. During an interview on 06/08/23 at 5:59 PM the ADMN stated her expectation was staffs response to call lights should have been 3 minutes or less and that call lights should have been attached to where a resident was sitting or have been easily accessed. The ADMN stated the effect on residents could have had a negative impact on the residents' physical and emotional wellbeing. The ADMN stated residents could have fallen or have wet on themselves which could have led to skin rash or breakdown and dignity issues. The ADMN stated the charge nurses were supposed to monitor while out on floor. The ADMN stated lack of training led to failure of staff not answering call lights timely or placing call lights in appropriate location. Review of facility policy titled Answering the Call Light dated October 21, 2010, revealed: When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Answer the resident's call light as soon as possible. 676053 Page 2 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to manage the personal funds of the residents deposited with the facility for 2 (Residents #16 and Resident #29) of 12 residents reviewed with trust funds. Residents Affected - Some The facility failed to ensure Residents #16 and Resident #29 had ready access to their personal funds on the weekends or if the BOM was not available. This failure could place residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings included: 1. Record review of electronic face sheet indicated Resident #16 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included urinary tract infection, muscle weakness, and anemia (low blood level). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS score of 07, which indicated her cognition was moderately impaired. During an interview on 06/08/2023 at 3:49 PM, Resident #16 stated she was only able to get her money from the BOM. She stated if the BOM was not working she is not able to get her money. She stated she had needed if before and was not able to get it. 2. Record review of electronic face sheet indicated Resident #29 was an [AGE] year-old female initially admitted to the facility 05/01/2021 with diagnoses which included chronic kidney disease, urinary tract infection, and arthritis. Record review of the Annual MDS assessment dated [DATE] indicated Resident #29 had a BIMS score of 11, which indicated her cognition was moderately impaired. During an interview on 06/06/2023 at 3:29 PM, Resident #29 stated no one was in the office and she was not able to get her money on the weekends. She stated if she needed money on a weekend, she was out of luck. During an interview on 06/07/2023 at 12:56 PM, the BOM stated residents could not get their money from their trust fund on the weekends. She was the only one who had access to their money, and she did not work weekends. She stated the residents were aware of that and they knew to ask on Friday if they were going to need any money. During an interview on 06/08/2023 at 5:44 PM, the Administrator stated residents could not get their money on the weekends and it had always been that way. She stated all residents knew they had to ask for money before the end of the day on Friday. She stated it was the residents right to be able to always have access to money. She stated she had not had any problems with that in the past. She stated the negative impact on the resident would be if they really needed or wanted something on the weekend, they would not be able to get it. The Administer stated the facility did not have a policy related to personal funds. 676053 Page 3 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician signed and dated all orders for 3 of 12 residents (Residents #14, #24, and #88) reviewed for complete and accurate medical records. The facility failed to obtain orders for bed rails for Residents #14, #24, and #88. This failure placed resident at risk for not receiving the appropriate physician ordered care. Findings Included: Record Review of the Resident #14's Face Sheet dated 06/08/2023, revealed she was a 91 yr. old Female, admitted to the facility on [DATE], with a diagnoses of Congestive heart Failure, open wounds, and skin conditions. Record Review of Resident #14's MDS, dated [DATE], Section C revealed a BIMS score of 09 (moderately impaired). Record Review of Resident #14's undated Care Plan, revealed, SIDE RAILS: (half rails) up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (every 2 hours) and as necessary to avoid iinjury. Record Review of Resident # 14's orders revealed no order for side rails. During observation on 06/07/2023 at 2:33 PM, Resident #14 had half side rails on bed up on both sides. Record Review of the resident #24's Face Sheet dated 06/08/2023, revealed she was a 79 yr. old female, admitted to the facility on [DATE], with a diagnoses of Cerebral Infarction (stroke), Pressure Ulcers and High BP. Record Review of Resident #24's MDS, dated [DATE], Section C revealed a BIMS score of 05 (severe impairment). Record Review of Resident #24's Care Plan revealed Date Initiated: 10/01/2022 with a Revision on: 10/05/2022 revealed, SIDE RAILS: half rails up as per Dr.s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition Q 2hrs and as necessary to avoid injury. Record Review of Resident #24's Orders revealed no order for side rails. During observation on 06/05/2023 at 3:13 PM, Resident #24 had half side rails on bed up on both sides. Record Review of the resident #88's Face Sheet dated 06/08/2023, revealed she was a 56 yr. old female, admitted to the facility on [DATE], with a diagnoses of Major Depressive Disorder, Moderate intellectual Disabilities, ADHD, and Degenerative Disease of Nervous System. 676053 Page 4 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #88's MDS, dated [DATE], Section C revealed a BIMS score of 07 (severe impairment). Record Review of Resident #88's undated Care Plan revealed, SIDE RAILS: (half rails) up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (every 2 hours) and as necessary to avoid injury. Record Review of Resident # 88's Orders revealed no order for side rails. During observation of Resident #88 on 06/05/2023 at 3:53 PM, 2 half side rails on bed were up. During an interview on 06/28/2023 at 6:21 PM, the Admn stated there should be orders for bed rails. She stated the charge nurse was responsible for putting those orders into the residents electronic charting if a verbal order, with the DON monitoring and following up on the orders. The Admn also stated if bed rails were care planned there should have been an order. She stated the failure occurred when the last DON left and the current DON was hired. The Admn stated there were orders for everything the resident need including bed rails. During an interview on 06/28/2023 at 6:38 PM, the DON stated, bed rails should always have an order. She stated the nurses were responsible for putting orders into the residents electronic charting if a verbal order and should have been done so within the same shift if not immediately. She stated it was a process but that should have been the first thing that was done if an order was received. The DON stated she should have been monitoring and making sure those orders were put in place. She stated the process of documenting an order would have been the entered order in PCC (Electronic Charting), afterward to have written a progress note, once done, she would have looked in the risk management tab which would show her new orders placed and Care Planned. She stated that should be done daily. The DON stated the negative impact could have been a hazard, with a possibility of residents crawling over the rails and falling. She stated the failure occurred with communication and continuance of care through reports. She stated her expectations were to have the resident assessed, talk to the Dr. and notify family for consent of the bed rails if needed. Record review of facility policy Use of Restraints with a revised date of 04/2017 revealed: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for the prevention of falls. Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 676053 Page 5 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0711 2. Level of Harm - Minimal harm or potential for actual harm The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove any device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over)., and this restricts his/her typical ability to change position or place, that device is considered a restraint Residents Affected - Some .4. Practices that inappropriately utilized equipment to prevent resident mobility are considered restraint and are not permitted, including: a. Using the balls to keep a resident from voluntarily getting out of bed has opposed to enhancing mobility while in bed; . .8. Treatment restraints may be used for the protection of the resident during treatment and diagnostic procedures with the resident and or representative has consented to the treatment for procedures the usual treatment restraint 676053 Page 6 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. Residents Affected - Some The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 7 days of the FY 1 Quarter out of 4 Quarters. (11/05/2022, 11/06/2022, 11/12/2022, 11/13/2022, 12/03/2022, 12/04/2022, and 12/17/202) This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record Review of facility's PBJ RN coverage report for FY Quarter #1 of 4 revealed: Days with no RN coverage: 11/05/2022, 11/06/2022, 11/12/2022, 11/13/2022, 12/03/2022, 12/04/2022, and 12/17/2022 In an interview on 06/08/2023 at 6:00 PM, the Admn stated her expectation was an RN to 8 hours a day 7 days week. She stated it was the Admn's responsibility to monitor and track. The Admn stated the failure could have been fewer incentives for RN's. She stated she also had not been able to find sufficient RNs that were willing to work and cover those specific areas needed. The Admn stated the negative effect on residents was possibly not having had specially trained nurses that could do the proper skills, assesses and procedures needed. During an interview on 06/08/2023 at 6:38 PM, the DON stated her expectation of RN Coverage, were the correct amount of coverage, being at least 8 hrs. a day minimum, every day of the week. She stated where there was no RN coverage for those days the facility was supposed to find someone within the facility staff or call Agency. During an interview on 06/08/2023 at 9:03 PM, the Admin, AIT, and DON, all stated there were no other documents before exiting of survey. Record review of facility policy of RN Coverage was not provided before exiting on 06/08/2023 at 9:03 PM 676053 Page 7 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 1 of 2 (Medication Cart 1) reviewed for medication storage. The facility failed to keep medication cart 1 secured when not in use, leaving resident medication in a locked compartment when not being immediately used. The failure placed residents at risk of adverse actions caused by inadvertent medication consumption as well as drug diversion. Findings included: During an observation on 06/05/2023 at3:04 PM, the medication cart 1 was unlocked by RN-Q being left in the hallway facing outward toward the open hallway, while administering medications in a resident's room. During an interview on 06/05/2023 at 3:05 PM, RN-Q stated she was the nurse in charge with the cart being hers. She stated the cart contained OTC drugs, heart disease medication, BP medications, diabetes medications, ALZ medications, with narcotics being left under one lock and not two which she knew was in the facility policy. During an interview on 06/05/2023 at 03:25 PMRN-Q stated the negative impact could be that a resident and/or staff member could have had access to medications that were not theirs. She stated residents could overdose or get the wrong medication and/or been allergic to a medication. RN-Q stated, there also could have also been a possible drug diversion. During an interview on 06/05/2023 at 4:38 PM, the DON stated, the medication carts should have been locked, with no medications left out. She stated she honestly did not know why the failure occurred. The DON then stated she had not spoken to RN-Q. She stated her expectations were for staff to know how to correctly perform their in-services they had previously learned. She stated she needed to pull the policies to understand them herself. The DON stated she should have monitored her staff with returned demonstrations and check off's before being placed on the floor. She stated, she had assumed the RN's knew what to do and felt they should had learned that in nursing school. She stated, it was her as the DON to monitor her staff but was busy and could not always watch. During an observation on 06/07/2023 at 5:30 PM the medication cart #1, located in the dining room with multiple residents close by, was unlocked with medications on top of the cart. The medications included: 1. Trazadone 50mg 10 tablets, 2. 676053 Page 8 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0761 Esomeprazole 11 capsules, and Level of Harm - Minimal harm or potential for actual harm 3. Amiodarone 4 tabs. Residents Affected - Some During an interview on 06/07/2023 at 5:35 PM, the Admn stated a nurse should never have left a cart unlocked as well as leaving medication on top of the cart. She stated she had previously instructed LVN-A not to leave the cart unlocked for any reason. She stated there were no excuses for that action, and that was totally unacceptable. During an interview on 06/07/2023 at 5:40 PM, LVN-A stated she was really nervous because the surveyors were asking her questions. She stated she should have never left her med cart unlocked because residents could get the wrong medications as well as be a drug diversion. Record review of facility policy Administering Medications with the revised date of 12/2012 revealed: . Policy Statement: .16. During administration medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aids. It may be kept in the doorway of the resident's room, with open doors facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medication, and all outward sides must be inaccessible to residents or others passing by personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification method are learned. Record Review of facility policy Security of Medication Cart with the revised date of 04/2017 revealed: Policy Statement: The medication chart shall be secured during medication passes. Policy Interpretation and Implementation: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 676053 Page 9 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0761 2. Level of Harm - Minimal harm or potential for actual harm The medication cart should be parked in the doorway of the resident's room hearing the medication test. The cart doors and drawers it should be facing the resident's room. Residents Affected - Some 3. When it is not possible to park the medication card in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication cards must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. 676053 Page 10 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 06/05/2023 between 10:00 AM and 11:15 AM revealed: Refrigerator 1. One opened bag of grated cheese with out an open date. 2. One opened package of brown sugar not sealed, exposed to air. 3. One opened package of ham without an open date. 4. One opened package of turkey without an open date. 5. One opened package of sliced cheese without an open date. Cook R was cutting pie without gloved hands and had whipped topping on his hands. During an interview on 06/05/2023 at 2:30 PM the DM stated her expectation was that staff wear gloves while preparing any food that was ready to eat, and that [NAME] R should have had gloves on while cutting and plating the pie. The DM stated effect on residents was cross contamination of food. The DM stated staff not thinking and being nervous were what led to the failure of not placing gloves on hands. The DM stated her expectation was that food items should have had an open date written on item and that food packages should have been sealed. The DM stated the effect on residents could have been residents received expired or not fresh food. The DM stated the weekend staff was new and that 676053 Page 11 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0812 was what led to the failure. The DM stated she was responsible for monitoring. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/08/2023 at 5:59 PM the ADMN stated her expectation was that staff follow policy and should have worn gloves when touching prepared food to eat. The ADMN stated that food items should be sealed and be dated with a receive date and open date. The ADMN stated residents could have been affected by causing them to become sick. The ADMN stated it was the DM's responsibility to monitor staff. The ADMN stated what led to failure was staff being nervous because surveyors where in the kitchen watching, and the DM was new to position and was constantly had to retrain staff. Residents Affected - Some Review of facility policy titled, Dietary Services- Food and Nutrition Services dated October 2017, revealed: Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. Review of facility policy titled, Food Safety dated February 1, 1968, revealed: Food is to tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored no more than 48 hours. 676053 Page 12 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 8 of 8 meetings (May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023) reviewed for QAPI. Residents Affected - Some The facility did not ensure the MD, or a representative attended QAPI meetings in May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023. The facility did not ensure the DON, or a representative attended QAPI meetings in July 2022, August 2022, and February 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for May 2022, July 2022, August 2022, September 2022, October 2022, December 2022, February 2023, and April 2023 indicated the MD or a representative did not sign in for the meetings. Record review of the facility's QAPI Committee sign-in-sheets for July 2022, August 2022, and February 2023 indicated the DON or a representative did not sign in for the meetings. During an interview on 06/08/2023 at 5:55 PM, the AIT stated QAPI was done every month but was only required every quarter. He stated the members that must be present included the Administrator, DON, MD BOM, AD, and EVS. He stated the DON was transitioning to a new DON and that was why the DON was not present. The ATI stated the ADON worked from home. The AIT stated since the facility transferred to a new MD in August 2022 it had been hard to get the MD to come to the facility. Record review of an undated form titled QAA Committee Information indicated the QAA Committee members were the Administrator, DON, ADON, BOM, DM, ECS, AD, MD. Record review of the facility's policy titled, SNF Quality Assurance Performance Improvement, dated 2017, revealed: . Our QAPI committee consists of a chairperson and seven sub-committees with representation from Administration, the Medical Director, Nursing, Dietary, Housekeeping, Laundry, Maintenance, Health Information Management, Activities, Infection, Preventionist, Staff, Development, Therapy, Human Resources, and the business office 676053 Page 13 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to 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 1 of 3 (RN-Q) staff observed during medication administration. Residents Affected - Some RN-Q placed her fingers inside the medication cup and the crushed the medication sleeve while preparing medication and without performing hand hygiene while administering medication. RN-Q did not sanitize the glucometer before or after use on a resident. RN-Q did not place lancet in the sharps box after use it on a resident. These failures placed residents of the facility at risk of infections from medication administration. Findings included: In an observation on 06/05/2023 at 3:30 PM of medication administration with RN-Q, she touched the inside of the medication cup with her bare hand touching the medication. After administering medication to the resident, RN-Q did not perform hand hygiene before continuing to prepare other residents' medications. She grabbed the medication from the pill cup with no hand hygiene before or after. In an observation on 06/05/2023 at 3:34 PM of medication administration with RN-Q placed a resident's medication in her bare hand to dispense to the resident. In an observation on 06/05/2023 at 4:04 PM RN-Q did not disinfect the glucometer or wash her hands before use of the glucometer. RN-Q placed a lancet in the resident's open trash can. RN-Q did not disinfect the glucometer after use, before returning it to the inside of medication cart. In an interview on 06/05/23 4:17 PM, RN-Q, stated she should have performed hand hygiene before she began preparing the medications for the residents. She stated she did not use clean technique by touching the pills numerous times with her bare hands and not using hand hygiene. She stated in not doing so, it could have cause contamination and was a likelihood of Cdiff, and/or VRE, especially in these residents. She stated she had training in nursing school but had not had any training or in-services from the facility on med administration. In an interview on 06/05/23 at 04:38 PM, the DON stated the insulin-glucometer was supposed to have been alcohol wiped before and after each use. She stated staff were supposed to throw the used lancets directly in the sharps container. The DON stated at any time medication was administered to residents staff should have never touched the medication with bare hands and their hands needed to be washed or sanitized with hand sanitizer after administration. The DON stated the policies revealed the medications were not supposed to be touched with ungloved hands. If using ABHR hands should have been washed after the 3rd use of ABHR, they should go do a full handwash. The DON stated she honestly did not know where the failure occurred and was unaware when RN-Q came on staff. She stated the failure also fell on her as she had not watched or checked her off on skills before placing her on the floor. Her expectations were for staff 676053 Page 14 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to know the in-services and stay informed on all facility policies. The DON stated she was supposed to have monitored RN-Q, and did so by walking through the hallways, and stated she was busy and could not always do so. She stated she had not checked her off previously on trainings or on skills, and had assumed her training in nursing school would suffice. Record review of facility policy labeled Glucometer Control Instruction Policy Signed by RN-Q dated 2-21-23 revealed: *Glucometers will be clean, even if it is a new machine, before and after each patient, with a disinfectant wipe and allowed to air dry. * Nurse will: wash hands Record review of facility policy labeled Handwashing/Hand Hygiene, with the revised date of 08/2019 revealed: Policy Statement: 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations; .b. Before and after direct contact with residents; c. Before preparing or handling medications .k. After handling used dressings, contaminated equipment, etc.; . .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infection. Record review of facility policy labeled Administering Medications with the revised date of 12/2012 revealed: Policy Statement: . .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administering of medications, as applicable. Record review of facility policy labeled Administering Oral Medications with the revised date of 10/2010 revealed: Purpose: 676053 Page 15 of 16 676053 06/08/2023 Merkel Nursing Center 1704 N 1st Merkel, TX 79536

F 0880 The purpose of this procedure is to provide guidelines for the safe administration of oral medications . Level of Harm - Minimal harm or potential for actual harm .Steps in the Procedure: 1. Residents Affected - Some Wash your hands . .9. Prepare the correct dose of medication: . e. Pour tablets or capsules from a bottle. Or the desired number into the bottle cap and transfer to the medication cup. Do not touch the medication with your hands. Return extra capsule/tablets to the bottle. All medications to be given at the same time can be placed in the same cup accept those that require assessment prior to administration. f. Or unit dose tablet or capsule. Place packaged medication directly into the medication cup. Record review of facility policy labeled Cleaning and Disinfection of Resident/Care Items and Equipment with the revised date of 10/2018 revealed: Policy Statement: resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogen Standard. Policy Interpretation and Implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g.durable medical equipment) . .3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 676053 Page 16 of 16