Health inspection·October 12, 2023

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 5 of 5 residents (Residents #2, #19, #25, #26 and #142) reviewed for nutrition services; in that: The facility failed to provide food that was in a form to meet resident needs for Residents #2, #19, #25, #26 and #142 who had orders for puréed diets. This failure could place residents at risk of decreased food intake and choking. The findings include: Resident #2: Record review of the Order Summary Report dated 10/11/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of abnormality of albumin (chemical imbalance related to protein), chronic kidney disease, unspecified, pain, unspecified, abnormal weight loss, unspecified, dementia, unspecified severity with other behavioral disturbance (cognitive impairment). Further record review revealed that the resident had the diet order, reflected , regular diet, purée texture, regular consistency, order date 1/18/23, start date 1/19/23. Record review of the annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of five which indicated that the resident had cognitive impairment. The MDS further reflected the resident had loss of liquid/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. Resident #19: Record review of the Order Summary Report dated 10/11/23 revealed that female Resident #19 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance (cognitive impairment), Vitamin D, deficiency, unspecified, abnormal weight loss, Further record review revealed that the resident had the diet order, regular diet, p purée texture, regular consistency, order date, 8/30/21, start date, 8/30/21. Record review of the Quarterly MDS assessment for a Resident #19 dated 7/25/23 revealed that the Page 1 of 16 676077 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0805 Level of Harm - Minimal harm or potential for actual harm resident had a BIMS score of two indicating that the resident was cognitively impaired. Further record review of the MDS revealed that the resident had loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. Further review revealed that the resident had missing teeth or tooth fragments . Residents Affected - Some Resident #25: Record review of the Order Summary Report for female Resident #25 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Hemiplegia and hemiparesis following cerebral infarction , affecting unspecified side (paralysis from stroke), dysphagia, unspecified (swallowing disorder), abnormal weight loss, and psychotic disorder with hallucinations due to known physiological condition (psychiatric issue). Further record review revealed that the resident had the diet order, regular diet, purée texture, regular consistency, order date 8/27/21, start date 8/27/21. Record review of the Quarterly MDS assessment dated [DATE] revealed that Resident #25 had a BIMS score of 10 indicating mild cognitive impairment. Further record review revealed the resident had loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals . Resident #26: Record review of the Order Summary Report for female Resident #26 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of abnormal weight loss, Parkinson's disease (neurological disorder), and unspecified, dementia, unspecified severity, with agitation (cognitive impairment). Further record review revealed the resident had the diet order, regular diet, purée texture, nectar consistency, order date 11/10/22,start date 11/10/22. Record review of the Quarterly MDS assessment for Resident #26 revealed that the resident had a BIMS score of two indicating the resident was cognitively impaired. Further review revealed the resident had loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals and coughing, or choking during meals or when swallowing medications . Resident #142: Record review of the Order Summary Report for female Resident #142 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of abnormal weight loss, mild cognitive impairment of uncertain or unknown ideology, and unspecified kidney failure. It was further revealed that the resident had the diet order, regular diet purée texture, regular consistency, order date 9/20/23 start date 9/20/23. Record review of the Quarterly MDS assessment dated [DATE] revealed Resident #142 had a BIMS score of seven indicating moderate cognitive impairment. Further record review revealed the resident had no swallowing issues. Record review of the Nutritional Follow Up Note dated 9/20/23 for Resident #142 revealed the following, . Resident is status post surgery with wound VAC. Diet: regular puree with house shakes . 676077 Page 2 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0805 (added 9/16/23). Diet texture changed to puree today, due to trouble chewing/swallowing. Dietitian Level of Harm - Minimal harm or potential for actual harm - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 11:03 AM and concluded at 12:15 PM: Residents Affected - Some Observations were made of Dietary staff A puréeing foods. She placed chicken fried steaks and broth in the processor and puréed the mixture. The appearance of the purée was very coarse. Dietary staff A, then placed cooked broccoli/cauliflower in the processor and puréed it. The appearance of the purée was very coarse. Observation on 10/10/23 at 12:13 PM, the Surveyor sampled the puréed chicken fried steak and the puréed broccoli and cauliflower with the following results: Purée, chicken fried steak - very coarse grainy with bits of gristle. Puréed, broccoli/cauliflower - very coarse and grainy. Observation on 10/10/23 at 12:16 PM another Surveyor also sampled the puréed broccoli and cauliflower and puréed chicken fried steak with the following results: Puréed chicken fried steak - required chewing to be consumed. Puréed broccoli and cauliflower - chunky/coarse. On 10/10/23 at 12:27 PM an observation was made in the dining room of residents who were served purée diets. Resident #26 was observed in a specialized high back wheelchair and was fed a puréed diet by staff. Her tray card reflected Level 4 diet. The resident had some coughing during the meal. The resident was served purée bread, purée chicken fried steak that was coarse in appearance, purée broccoli cauliflower was coarse in appearance, thickened water, thickened tea and pudding. On 10/10/23 at 12:28 PM Resident #2 was observed in the dining room and was being fed by staff a puréed diet. The resident was obese, used oxygen and was in a Geri chair. The resident was served tea, water, pudding, and puréed broccoli cauliflower and puréed chicken fried steak that were very coarse in appearance. Resident #2 also received puréed bread and mashed potatoes. The resident was observed coughing during the meal. Her tray card reflected Level 4 diet. On 10/10/23 at 12:30 PM Resident #142 was observed in the dining room being fed by staff a puréed diet. The tray card reflected at Level 4 diet. The puréed broccoli/cauliflower and puréed chicken fried steak were very coarse in appearance. The resident received purée bread, pudding, mashed potatoes and water . On 10/10/23 at 12:33 PM Resident #19 was observed in the dining room being fed by staff a puréed diet. Her tray card reflected Level 4 diet. She was served puréed broccoli and cauliflower, puréed chicken fried steak and both were coarse in appearance. She received puréed bread, pudding, mashed potatoes, and water . 676077 Page 3 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/10/23 at 12:34 PM an observation was made of Resident #25 in the dining room, and she fed herself. The resident received a puréed diet which consisted of purée broccoli and cauliflower and puréed chicken fried steak, which were both coarse in appearance. She also was served pudding, puréed bread, mashed potatoes. - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 5:29 PM and concluded at 5:55 PM: Meal service started on 10/10/23 at 5:45 PM and on the steam table were potatoes, zucchini, carrots, roast beef, puréed potatoes, puréed zucchini, puréed roast beef and pureed carrots. The puréed carrots and puréed roast beef had a coarse appearance. The puréed foods were prepared by Dietary staff B. On 10/10/23 at 5:47 PM the meal tray for Resident #2 was observed prepared and the resident was served applesauce, puréed carrots, puréed zucchini, puréed potatoes, and puréed roast beef. The puréed carrots had a coarse appearance as did the roast beef which was more of a stringy lean coarseness . On 10/10/23 at 5:51 PM, the Surveyor sampled the pureed roast beef, carrots, potatoes and zucchini. The results were as follows: Puréed zucchini - OK, texture was correct Puréed carrots - grainy Puréed roast beef - stringy and needed to be chewed to be consumed. Puréed potatoes - grainy texture. On 10/11/23 at 9:38 AM an interview was conducted with the Dietary Manager regarding puréed diets. She stated the meal software was what they used as guidance and that they went by the IDDSI Level 4 definition for puréed diets. She added that the consistency of a puréed diet would be like baby food. Regarding if she had conducted any training related to puréed foods, she stated yes. She added, the IDDSI guide info was given to employees regarding purées. She stated that she had an in-service in June related to purées. On 10/11/23 at 9:43 AM the Dietary Manager was interviewed regarding training new employees and related to the coarse texture of the purée. She stated that new employees were also trained regarding puréed diet. She added, the Dietitian had come in the past, and there was a problem with their purées being too thin. She stated she would conduct a refresher training on purées. She added she should have caught the errors with the puree consistency. Regarding why the issues occurred with the purée diets, she stated with a chicken fried steak, the issue was the breading; it thickened after setting. She added purées were served at the end of the meal service, and they should have checked them again. She stated they should have cooked the vegetables longer and it was the same with the potatoes. She stated October 1, 2023 she was appointed dietary manager and stated the responsibility was on her for ensuring foods were in the correct form. She added the dietary department was shorthanded. Regarding what she expected staff to have done related to puréed diets, she stated the beef should have been puréed longer and the vegetables should have been puréed more. The vegetables should have been cooked longer. Regarding what could 676077 Page 4 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0805 result from the puréed foods was not being in the correct form, she stated resident aspiration. Level of Harm - Minimal harm or potential for actual harm On 10/11/23 at 2:51 PM an interview was conducted with Dietary staff B regarding the coarseness of the purees she prepared for the evening meal on 10/10/23. Regarding why the purée was coarse, she stated she had an emergency and that was why it happened . Residents Affected - Some On 10/11/23 3:53 PM an interview was conducted with LVN A regarding why the following residents were on purées diets, she stated Resident #26 had swallowing issues; Resident #2 had difficulty chewing; Resident #142 had a change after she was hospitalized and declined; Resident #19 had swallowing issues and Resident #25 did not chew or swallow well. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator. Regarding food form and why the issues with puréed diets occurred, he stated he assumed staff were not knowledgeable or lacked the ability to have puréed the foods correctly. He stated staff should have puréed Tweethe foods correctly and produced the proper texture. He stated the cook and Dietary Manager were responsible for ensuring foods were in the correct form. He stated a choking hazard, aspiration, and having difficulty swallowing could result from foods not being in the required form. On 10/12/23 at 11:36 AM an interview was conducted with Dietary staff A regarding the purée she produced for the noon meal on 10/10/23, she was asked why the purée was coarse, and she stated when she placed it on the steam table, it got thick. Regarding what could result from purées not being in a puréed form, she stated residents could choke. Record review of the In-Service Training Report document dated 6/12/23 revealed that an in-service with the Subject: Purée diets. Summary of Meeting reflected, Explained the proper technique and importance of proper puréed texture diets. Reviewed IDDSI guidelines . Dietary staff A and B attended the in-service. Record review of the facility's current guidelines titled IDDSI, International Dysphagia Diet Standardization Initiative, . 4 PURÉED, dated January 2019 revealed the following, Level 4 Puréed Food for Adults. What is this food texture level? Level 4 - Puréed Foods: -Are usually eaten with a spoon -Do not require chewing. -Have a smooth texture with no lumps. -Hold shape on a spoon -Fall off a spoon in a single spoonful when tilted -Are not sticky? 676077 Page 5 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0805 -Liquid (like sauces) must not separate from solids. Level of Harm - Minimal harm or potential for actual harm Why is this food texture level use for adults? Residents Affected - Some Level 4 - Puréed food may be used if you are not able to bite or chew food or if your tongue control is reduced. Record review of the facility policy, titled Policy: Consistency Modification of Foods. Department: Dietary. Effective: March 2021, Policy Number: 5.10, revealed the following, Policy: It is the policy of this home that dietary services will provide modified consistency (modified texture) food to meet the individual needs of the residents as recommended by the SLP and ordered by the physician. Standardize recipes are to be followed for menu adherence . Procedure 1. Orders for texture or consistency. Modification must be added to the resident's therapeutic diet order. These orders are generally used to address swallowing and/or chewing problems and are based on the individual resident's needs. d. Puréed foods are regular menu items, with some exceptions, that are prepared with a food processor to form a cohesive and homogeneous bolus. The desired consistency of pureed foods is mashed potatoes to pudding; however, applesauce and other puréed fruit may be appropriate in texture to meet the needs of a resident therefore the use of a thickener is not indicated. Puréed meats should be served with gravy and sauces for enhancing flavor of foods. Water is never to be added as a liquid to puree a food; the cook should refer to the puréed standardized recipe for the correct liquid to add for the menu item Record review of the facility policy titled Policy: Diet Conversion List. Department: Dietary. Effective: March 2023, Policy Number: 5.01A, revealed the following, Policy: Diet order should be liberalized to the extent that meets the residents, nutritional needs and/or expectations. Procedure: Per menu and diet extensions the facility uses the following diets are what are available to order and use. Diet order with different names will be changed to diet and diet extensions that are available in the dietary department. Diet Conversion List. Diet Ordered. Puree. Use This Diet Order. IDDSI 4. Record review of the facility policy titled Policy: Preparation of Food. Department: Dietary. Effective Date: March 2021, Policy Number: 2.01, revealed the following, Policy: It is the policy of this home is food to be prepared by methods that conserve nutritive value, flavor and appearance under sanitary conditions. Procedure. 2. All foods . will be . in a consistency (form) to meet the individual needs of the resident. 5. Food and beverages will be modified to meet individual needs of the resident and served according to the diet orders and current menu cycle. 676077 Page 6 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

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, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure foods were processed and puréed under sanitary conditions. 2) The facility failed to ensure dietary staff ensured food and non-food contact surfaces were clean. and 3) The facility failed to ensure foods were stored in a manner to prevent contamination. These failures could place residents at risk for food contamination and foodborne illness. The findings included : - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 11:03 AM and concluded at 12:15 PM: In refrigerator #4 there were two unshielded lightbulbs. Freezer #3 had a heavy buildup of ice and frost on one of two sides. The lower shelf of the prep table near the stove was soiled with gummy grease . In the walk-in refrigerator, there was a box of garlic bread that was opened and uncovered which exposed it to contaminants. There was a large plastic bag of thawed raw stew meat stored in the same bin next to two fully cooked boneless hams. The ice scoop handle was dirty, in the ice machine. The handle had a yellow brown buildup on the handle grooves. Dietary staff A placed slices of bread and apple juice in the processor and puréed the food. She then took the processor to the dishwasher to wash. After she washed the processor, the Surveyor observed that there was a large area (approximately 2) of puréed bread and food debris on the interior of the processor pot and lid. The Surveyor intervened and pointed out to Dietary staff A that the processor pot and lid was still soiled with food. Dietary staff A then took the parts to the dishwasher and ran them through the dishwasher. The processor was still wet and there was food debris in the lid after washing. Dietary staff A washed the processor parts in the dishwasher again two more times due to food debris remaining on the parts. After the last washing, Dietary staff A was observed placing the blade in the processor pot and it was still wet after coming out of the dishwasher. She then used her bare hands and wiped the water off the blade and lid interior. She then placed broccoli in the processor and puréed it. - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 5:29 PM 676077 Page 7 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0812 and concluded at 5:55 PM: Level of Harm - Minimal harm or potential for actual harm There was heavy ice buildup inside of freezer #1 There was heavy ice buildup in freezer #3 (1 of 2 haves). Residents Affected - Many Refrigerator #4 had two of two interior lights that were not shielded. In the walk-in refrigerator, there was still a bag of thawed bloody stew meat in a bin stored with 2 cook hams. Dietary staff B made the puréed foods for evening meal . She puréed potatoes, then zucchini. After that, the Dietary Manager sent the processor parts through the dishwasher and then wiped the interior of the pot and blade with a paper towel. She did not allow them to air dry. After that, Dietary staff B then puréed meat in the processor. Dietary staff C was observed putting her foot on the lower shelf of the prep table near the stove. There were jugs of oil stored on the shelf. - The following observations and interviews were conducted during a kitchen tour beginning on 10/11/23 at 9:25 AM and concluded at 9:55 AM: On 10/11/23 at 9:28 AM an interview and observation were conducted with Dietary staff A. There were two cooked hams on a cart in a bin in the kitchen. Regarding where she obtained the two cooked hams that were on the kitchen cart, she stated, she got them from the bin where the thawed raw stew meat was stored in the walk-in She stated she was aware raw and cooked foods should not be stored in the same container. She added she had looked for another bin at the time, and that bin with the raw meat was the only place to store the cooked hams. On 10/11/23 at 9:40 AM an interview was conducted with Dietary staff A regarding what could result from raw and cook foods being stored in the same container. She stated someone could get sick. Two of two lights were unshielded in refrigerator #4. - The following observations and interviews were conducted during a kitchen tour beginning on 10/11/23 at 2:51 PM and concluded at 3:33 PM: Refrigerator #4 had two of two unshielded lights. The ice scoop in the ice machine still had a yellow brown substance along the crevices on the ice scooper handle. The underside of the stove's upper shelf had a buildup of splatter, grease and food. On 10/11/23 at 2:53 PM interview and observation were conducted with the Dietary Manager regarding dietary sanitation issues in the facility. She stated the hospital was going to get a company to check the refrigerator lights and freezer ice buildup and the gaskets had been changed previously on the freezers. She stated she was not aware that the lights in the refrigerator were not shielded. She stated she did not know the shields were needed. Regarding why the processor pot was dried with a 676077 Page 8 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many paper towel instead of allowing it to air dry, she stated, staff were told paper towels could be used to dry equipment. Observation of the Low Temperature Dishwasher Sanitizer, connected to the dishwasher, revealed the following, .Sanitation. Tableware Sanitizer and Destainer for Mechanical Spray Warewashing Machines. Air dry or follow with a potable water rinse. Regarding the storage of the ready to eat foods with raw meat, she stated produce should be on the other side of the walk-in refrigerator away from raw meat. She further stated that raw and cooked food should not have been stored together. At that time , observation in the walk-in , there was a bin of raw cabbage observed on a shelf with bins of thawed raw meat. She stated the issues were unacceptable, and the department was shorthanded. She added sometimes staff forgot to do things and staff were moving too fast. Regarding what she expected staff to have done, she stated she started in January 2023 as the assistant Dietary Manager and was appointed October 1 (2023) as the Dietary Manager. She stated she wished staff would have slowed down and paid attention. Regarding whom was responsible for ensuring that dietary sanitation procedures were correct in the kitchen, she stated the Dietary Manager and staff. Regarding what could result from the issues observed related to dietary sanitation, she stated residents could get deathly sick. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator. Regarding why the dietary sanitation issues occurred, he stated staff were not following proper steps they were trained on. He stated staff should have done what they were trained to do. He stated each staff member and the Dietary Manager were responsible for ensuring that dietary sanitation functions were carried out correctly. Regarding what could result from dietary sanitation procedures not being carried out correctly he stated contaminated food, items not sanitized and shattered lightbulbs. On 10/12/23 at 11:36 AM an interview was conducted with Dietary staff A. Regarding why she did not allow the processor pot, lid and blade to air dry when she made the puréed foods, she stated she usually allowed the equipment to dry, and she was in a hurry. Regarding what could result from not allowing equipment to air dry as required, she stated that was not good because the equipment could have soap in it. She added residents could become ill. Record review of the In-Service Training Report dated 8/14/23 revealed a Subject title: Cleaning/Sanitation., Summary of Meeting revealed the following, Keeping dietary clean and sanitize. Dietary staff A and B attended the in-service. Record review of the In-Service Training Report dated 9/18/23 revealed, Subject: Dietary policies and procedures., The Summary of Meeting revealed the following, Dietary policies and procedures. Dietary staff A and B attended the in-service. Record review of a facility policy titled Policy: Equipment Sanitation. Department: Dietary. Effective: March 2021, Policy Number: 4.03, revealed the following documentation, Policy: Kitchen equipment will be cleaned and sanitized between uses to prevent cross-contamination and foodborne illness. Procedure: 1. All equipment must be thoroughly washed, and sanitized between uses and different food preparation tasks (e.g., Salad preparation, raw meat cutting, and cooked meat cutting). All items will be sanitized by one of the following methods: a. Washed and sanitized through use of the dish machine with 50 to 100 ppm chlorine bleach solution 676077 Page 9 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0812 e. All items washed and sanitize will be air dried. Level of Harm - Minimal harm or potential for actual harm 5. Blender, mixer, and food processor bowls should be washed and sanitize, and inverted to air dry on shelves with vented slots to allow for adequate air circulation. Residents Affected - Many Record review of the facility policy titled Policy: Cleaning Schedules. Department: Dietary. Effective: March 2021, Policy Number: 4.04, revealed the following documentation, Policy: The dietary services department and all equipment in the kitchen will be cleaned on a regularly scheduled basis, following the cleaning schedules, provided for daily, weekly and monthly tasks Record review of the facility policy titled Policy: Food Safety. Department: Dietary. Effective: March 2021, Policy Number: 4.19, revealed the following documentation, Policy: It is the policy of this home that food will be handled in a safe and sanitary method to prevent contamination and foodborne illness. Procedure. 7. The ice scoop is to be washed and sanitized daily Record review of the facility policy titled Policy: Handling Potentially Hazardous Foods. Department: Dietary. Effective: March 2021, Policy Number: 4.20, revealed the following documentation, Policy: It is the policy of this home to establish safe and sanitary methods of handling potentially hazardous foods (PHF). A potentially hazardous food (PHF) is a food that consists in part of milk or milk products, meat, poultry, fish, eggs, shellfish, low acid canned items, fresh melons, and other ingredients in a form capable of supporting rapid progressive growth of microorganisms. Procedure. 2. Meat, Poultry, and Fish. d. Avoid cross-contamination between raw and cooked foods. Record review of the facility policy titled Policy: Food Storage - Refrigerated and Frozen Foods. Department: Dietary. Effective: March 2021, Policy Number: 4.21, revealed the following documentation, Policy: Refrigerators and freezers will be kept clean and sanitized. The procedures to maintain the proper temperature for storing cold foods will be strictly followed to prevent foodborne illness. Procedure. 4. Storage refrigerators and freezers shall be kept clean and organized . 11. Store ready to eat and cooked foods above raw meat, poultry, and fish to prevent raw food juices from dripping into ready to eat or cooked food that can cause foodborne illness. 14. Freezer should be defrosted regularly so that they will operate more effectively 676077 Page 10 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure personnel stored linens so as to prevent the spread of infection in 2 of 4 baths (Hall 100 (large) and Hall 200 (large)), in that: Residents Affected - Some The facility failed to store clean linens in a sanitary manner in 2 of 4 common baths (Hall 100 (large) and Hall 200 (large)). This failure could result in the spread of resident infections. The findings include: Observation on 10/10/23 at 4:54 PM revealed the large bath on hall 100 had large amounts of towels and wash cloths stored on open uncovered metal racks in the bath. There were approximately, 105 towels and 125 washcloths. On 10/10/23 at 5:04 PM o hall 200 large bath was observed. There was a large amount of towels and washcloths on open, uncovered metal racks in the bath. There were approximately 100 towels and 125 washcloths on the open rack that were unprotected. There was also a covered soiled linen cart present in the bath. On 10/11/23 at 10:10 AM Laundry staff A was observed stocking the hall 200 large bath with linens. On 10/11/23 at 10:12 AM an interview and observation were conducted with Laundry staff A. Regarding the amount of towels and washcloths in the laundry, she stated she checked the linen supply in the baths one time a day or three times a week to restock. She stated besides stacking clean linens on the metal racks, she stacked linens on top of a chest of drawers located in the bath. Observation of the linen rack at this time revealed that there were approximately 200 towels, and 200 washcloths on the metal racks in the hall 200 large bath. Next to the racks were shower shoes/boots that were stored nearest the lowest shelf that contained linens. On 10/11/23 at 10:26 PM an observation was made of the large 100 hall bath. There was a soiled linen barrel present, which was covered and 3/4 full. There was a trash bin present, which was covered and contained gloves/briefs that were soiled. There was approximately 150 towels and 100 washcloths, clean and stored on the open metal rack in the bath. The soiled linen barrel, and trash bin were approximately 10 feet away from the clean linens. The air in the bath was humid. The shower stall was wet. Next to the racks of linens, was the whirlpool, which was dusty, and had some bits of debris. There were cleaning brushes on the walls hanging next to and above the rack of clean linens. The restroom door was also open in the room. CNA A was in the bath at this time cleaning and preparing for the next bath. On 10/11/23 at 10:35 AM CNA A was observed wheeling a resident into the hall 100 large bath. The clean linens, soiled linen barrel and trash bin were still present and full. On 10/11/23 at 11:59 AM observation in the large 100 hall bath revealed there was still racks of clean linens present, and the soiled linen barrel was present. CNA A was in the bath cleaning. On 10/11/23 at 12:22 PM an observation was made of the large bath on hall 100. There were racks of 676077 Page 11 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0880 Level of Harm - Minimal harm or potential for actual harm clean linens, towels and wash cloths on the open metal racks, and there were approximately 200 towels, and 150 washcloths present. The barrel was full of soiled towels and the room was humid with no active showers being conducted. The trashcan was filled with soiled gloves. The soiled linen barrel and trashcan were covered. The whirlpool was dusty with debris. There was a bariatric shower chair present near the towel racks, and there was a wheelchair present in the corner. Residents Affected - Some On 10/11/23 at 1:01 PM an interview was conducted with CNA A regarding the clean linens being stored in the bath. She stated she had worked in the facility six months and that was the way the clean linens towels and washcloths had been stored since working there. She added the soiled barrels were taken out of the baths every day to empty and the soiled barrel was always stored there in the bath. She also stated that she normally gave 13 to 15 baths a day. She added she gave seven or eight on hall 100 today (10/11/23) so far. Regarding what could result from leaving clean linens in a soiled area, she stated if a resident was sick, it could spread infections and illness could spread easily. On 10/12/23 at 9:37 AM interview was conducted with Infection Control Preventionist/ADON regarding linen infection control situations in the facility. She stated initially she did not think of the current linen storage issue as an infection control situation. Regarding why the situation occurred, she stated the linens were in the baths due to storage space. She stated there was a lack of space and there was more available in the baths. Regarding what she expected staff to have done, she stated initially when residents moved in the facility the linens were stored in a clean linen closet. Regarding whom was responsible for ensuring that linens were stored in a sanitary manner, she stated the laundry department. During this interview, the BOM stated she previously worked in central supply and recalled the laundry department did not request to store the linens in the baths. Regarding what could result from storing the clean linens in a soiled area, the ADON stated contamination due to splash, body fluids, feces and humidity. She added that she had not conducted any in-services related to storage of clean and soiled linens. She added that new hires were told that clean linens were to be stored away from their bodies, soiled linens should be bagged, and soiled linens should be taken out twice a shift. She stated staff were shown where linens were stored, but storage of linens in baths was not addressed. She further stated staff would need to be re-educated on linen storage. Regarding how long she had been the Infection Control Preventionist, she stated a little over a year. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator. Regarding why the linen storage situation occurred, he stated that was something the facility had not considered; storage was taken where it was available. Regarding what he expected staff to have done, he stated it was the staffs job to catch the situation; staff were operating the way they were supposed to. Regarding whom was responsible for ensuring that clean linens were stored in a sanitary manner, he stated he Administrator and Infection Control. Regarding what could result from the storage of clean linens in a soiled area, he stated, infection transmission could occur. On 10/12/23 at 10:51 AM an interview was conducted with the DON. Regarding what could result from clean linens being stored in the soiled area, he stated it could lead to infection and cross contamination. He stated he was not sure if in-services had been conducted on linen storage. Regarding why he felt the situation happened, he stated the facility had initially stored linens in the supply room, and then there was an overflow problem. He added the facility did not have room in the storage rooms, so clean linens were moved to the showers. Record review of the facility policy, titled Departmental (Environmental Services) - Laundry and Linen, Level 1, Revised January 2014, revealed the following documentation, Purpose. The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of 676077 Page 12 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0880 linen. General Guidelines . Washing linen and other soiled items. Level of Harm - Minimal harm or potential for actual harm 6. Keep soiled and clean linen, in their respective hampers and laundry carts, separate at all times. Residents Affected - Some 7. Clean linen will remain hygienically, clean, (free of pathogens, in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. 676077 Page 13 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. 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 ensure resident rooms were designed or equipped to assure full visual privacy for each resident in 23 of 23 identified semi-private resident rooms reviewed (Rooms 101 - 116, 202, 204, 206, 208, 210, 212 and 214), in that: Residents Affected - Some The facility failed to ensure semi-private resident rooms provided full visual privacy at the window area beds. This failure could place residents at risk of being exposed while receiving personal care. The findings include: Observation on 10/10/23 at 4:35 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. If an individual in the door bed went to their chest of drawers, they would be able to view the resident in the window area bed receiving care. Observations on 10/10/23 at 4:38 PM and 10/11/23 at 12:07 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. The window bed was occupied by Resident #16, and the door bed was occupied by Resident #1. Observation on 10/10/23 at 4:44 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. Observations on 10/10/23 at 4:47 PM, 10/11/23 at 10:08 AM and 10/11/23 at 12:13 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. The residents in the rooms were Resident #17 and Resident #8. Resident #8 was in the window area bed and Resident #17 was in the door area bed. Observation on 10/10/23 at 4:50 PM and 10/11/23 at 12:20 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. Residents #27 and #15 resided in the room and Resident #15 occupied the bed nearest the window. On 10/11/23 3:53 PM an interview was conducted with LVN A. She stated the following regarding the incontinent status of these residents and need for assistance: -Resident #8 was occasionally incontinent. -Resident #17 was occasionally incontinent. 676077 Page 14 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0914 -Resident #1 was mostly incontinent. Level of Harm - Minimal harm or potential for actual harm -Resident #16 was incontinent and needed assistance with incontinent care. -Resident #15 and Resident #27 were continent. Residents Affected - Some On 10/12/23 at 9:14 AM an interview was conducted with LVN B regarding mobility of the following residents. She stated the following: -Resident #17 could transfer, stand and walks in her room, and she self-propelled in her wheelchair. -Resident #27 could stand and walk. She could wheel herself to the dining room and walked in her room. -Resident #1 could walk independently. On 10/12/23 at 9:17 AM observation in room [ROOM NUMBER] revealed the distance from the center privacy curtain to the window was approximately 8 feet. There was no privacy curtain that was ceiling suspended at the window bed. On 10/12/23 at 9:20 AM observation in room [ROOM NUMBER] revealed the center privacy curtain was approximately 8 feet from the window and there was no ceiling suspended privacy curtain at the of the window bed. On 10/12/23 at 9:22 AM observation in room [ROOM NUMBER] revealed the center privacy curtain was approximately 8 feet away from the window wall and there were no ceiling suspended privacy curtains at the window bed side. On 10/12/23 at 9:24 AM observations in room [ROOM NUMBER] revealed Resident #41's bed was at the door, and Resident #2's was at the window. Resident #41 was confused, wandered and walked. Resident #2, who was by the window was in bed, used oxygen, had a catheter , and was confused. Further observation of the room revealed that it was designed in the same manner as rooms 104, 106, 108, 110 and 112. The center privacy curtain was approximately 8 feet from the window wall and there were no ceiling suspended privacy curtains on the window side bed. The Surveyor stood at the door area chest of drawers and could fully view Resident #2 in the window area bed. On 10/12/23 at 9:32 AM observations were made of the 200 hall rooms and checked which rooms had two beds (and currently considered semi-private) with no privacy curtain at the window bed that was ceiling suspended to provide full visual privacy. The following rooms designed in this manner were 202, 204, 206, 208, 210, 212 and 214. On 10/12/23 at 9:34 AM an observation was made of hall 100 rooms regarding those that had two beds and had no ceiling suspended privacy curtains at the window bed. The following rooms were 101 through rooms 116 (currently considered semi-private); 16 rooms. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator regarding the missing ceiling suspended privacy curtains at the window area bed in semi-private rooms. He stated that was the first time the privacy curtain issue had come up. Regarding why the situation occurred, he stated it 676077 Page 15 of 16 676077 10/12/2023 Stonewall Living Center 931 N Broadway Aspermont, TX 79502

F 0914 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had not been brought to the facility's attention initially. He further stated the hospital had privacy screens but was unsure if there was enough of them for each room. Regarding what he expected staff to have done, he stated there was nothing told to them about the missing privacy curtains by the architects. He stated that he expected the inspection personnel to have mentioned that also. Regarding whom was responsible for ensuring that the privacy curtains were installed as required, he stated the building contractors. Regarding what could result from not having the ceiling suspended privacy curtains at the window area bed, he stated residents would not be provided the dignity deserved if someone peeked around the curtain. On 10/18/23 at 8:41 AM and interview was conducted with the Administrator. He stated that residents were moved from the old facility to the current facility on 6/10/20. He added that there was no waiver regarding ceiling suspended privacy curtains. Record review of the facility's Salesforce Account revealed the following, Bed Notes. EFF (effective) 05/21/2020 [Previous Name of Facility] CONSTRUCTED A NEW BUILDING AT [address] . LSC WAS APPROVED ON 05/21/2020 FOR A CAPACITY OF 53 BEDS, 38 SNF/NF; 15 SNF Record review of the current undated facility policy titled Subject: Resident Rights to Privacy and Confidentiality. Policy LTC11011, Department: Long-Term Care, revealed the following documentation, Policy: facility staff shall observe and respect resident's rights to privacy and confidentiality. This includes all employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the long-term care facility. Every nursing home resident has the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations, and personal care. Administrator shall be responsible for providing ongoing oversight, and supervision to ensure staff are not engaging in activities that violate the resident's rights of privacy and confidentiality. 676077 Page 16 of 16