Health inspection·December 14, 2022

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director Qualifications. Residents Affected - Some The facility did not ensure the Activity Director completed the required training to serve as the director of the activities program. This failure could place residents at risk of not having an overall skilled and knowledgeable Activities Director to direct an effective activities program, which could result in the residents not receiving activities to meet their needs. Findings include: Record review of the Activity Director's Personnel record revealed her hire date was 01/03/22 and there was not any documentation of certification or Activity CEU's or therapist certification in her file. Interview on 12/12/22 at 10:15 am, the Administrator stated their Activity Director was currently working to get her Activity Director Certification and they had no other Certified AD who worked at this facility. Interview on 12/13/2022 at 4:32 pm, the Activity Director stated she started working at this facility in January 2022 and did not have her Activities Director certification. She stated the Administrator told her when she became the AD, she would have to complete a certification class. She stated the MEPAP course was a self-paced online program she started about six months ago. She stated she did not have a bachelor's degree and was not an Occupational Therapist and Occupational Assistant. She stated she knew what she was doing as an AD and talked to the SW or MDS nurse if she had any questions about anything. She stated she planned the resident's day to day activities such as cooking, coloring, baking and anything they could have potentially done in the past. She stated she graduated from high school last year and worked at a restaurant and as the receptionist at this facility before getting the AD position. She stated she had completed 85% of the MEPAP certification course. She stated not being a certified AD could cause her to be incapable of doing her job effectively and could also lose this job if she did not get certified. She stated if she had the opportunity to have completed the MEPAP course before she became the AD she would have done so. Interview on 12/14/22 at 3:25 pm, the Administrator stated the AD started working at this facility as a receptionist a year ago and she became the AD around February or March 2022. He stated he was aware the AD had to be certified and the facility's AD started her Activity Director Certification in Page 1 of 6 676104 676104 12/14/2022 Grapevine Medical Lodge 1005 Ira E. Woods Parkway Grapevine, TX 76051

F 0680 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some April 2022. He stated the AD should complete her certification training around the end of January 2023 and stated she had no other qualifications to be the AD. He stated the AD was supervised by the Social Worker and the Occupational Therapist and the Occupational Therapiat was not directing the Activity program and completing the resident's Activity Assessments. He stated none of the residents were affected from not having a qualified AD, and the only negative outcome was that the facility would be getting a deficiency. He stated there was no harm or negative outcomes to the residents for not having a qualified AD. Record review of the Facility's Activity Director's Job Title undated revealed, Responsibilities: Work in planning, coordinating and providing an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest, and physical, mental and psychosocial well-being of each resident. Arrange for use of any community facilities. Recruits, orients, and supervises the volunteer program of the facility and provides all necessary documentation .Qualifications: Completed an activity director training course approved by any state. These courses must be approved by recognized body, such as the National Certification Council for Activity Professionals, the National Therapeutic Recreation Society, or the Consortium for Therapeutic/Activities Certification . Record review of the Facility's Activity Programs - Staffing policy dated 2001 and revised August 2006 revealed, Policy Statement: Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interest of each resident .Policy interpretation and Implementation: 1. Our activity programs are under the direct supervision of a qualified professional who: is a qualified therapeutic recreation specialist .has two (2) years of experience in a social or recreational program within the last five (5) years .is a qualified Occupational therapy or Occupational therapy assistant or has completed a training course approved by the state 676104 Page 2 of 6 676104 12/14/2022 Grapevine Medical Lodge 1005 Ira E. Woods Parkway Grapevine, TX 76051

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable Residents Affected - Few environment and to help prevent the development and transmission of communicable diseases and infections for 2 (LVN C and MA D) of 2 staff observed for infection control practices. While administering Resident #77's medications, LVN C did not change gloves or perform hand hygiene between touching the PEG tube, feeding pump tubing, syringe, and bed sheet and putting her hand in a cup of water to retrieve the medication stirrer. MA D failed to touch medication dose cups on exterior surfaces only. These failures could place residents at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Observation on 12/12/22 at 8:44 AM revealed LVN C donning gloves to administer crushed medications in individual dose cups to Resident #77 by placing 5 ML of water into crushed medication and stirring with a wooden spoon, then dropping the wooden spoon into a filled cup of water. LVN C poured the dose cup contents into a syringe connected to PEG tube, using gloved hands to touch PEG tube, feeding pump tubing, syringe and bed sheet. LVN C did not change/remove gloves after administering medications and before LVN C poured 5 ML of water from water cup containing wooden spoon and then use gloved fingers to reach into water and retrieve wooden spoon which LVN C again used to stir dose cup containing water and crushed medications. LVN C was observed to repeat same process for multiple medications given individually. LVN C was observed to use the same gloves throughout medication administration process. Observation of MA D during routine medication pass revealed MA D repeatedly using bare hand(s) to 676104 Page 3 of 6 676104 12/14/2022 Grapevine Medical Lodge 1005 Ira E. Woods Parkway Grapevine, TX 76051

F 0880 touch dose cup lips and carrying dose cups using thumb and forefinger with forefinger on inside of cup Level of Harm - Minimal harm or potential for actual harm and thumb on outside of dose cup(s) containing medication. Interview on 12/12/22 at 10:00 AM with LVN C stated she had always dropped wooden spoon (used to Residents Affected - Few stir medications when adding water to dose cup medications) into cup of water used for medications and PEG tube flush and then used fingers to retrieve spoon to stir next medication. LVN C stated she was followed by surveyor on last survey and was not cited for same action. LVN C stated she did not realize she had allowed syringe tip to touch bed sheets. LVN C stated allowing syringe to touch sheet was cross contamination and should not occur. LVN C stated she had not changed gloves after administering each medication. When surveyor asked LVN C why she had touched feeding pump tubing, PEG tube, syringe and bed sheets and then used same gloves to retrieve wooden spoon from water used for medications and PEG tube flushes, LVN C responded she had always administered PEG tube medications that way and no one had ever said anything. When surveyor asked if cross-contamination was an issue LVN C responded, Yes. Interview and Observation on 12/12/22 at 8:14 AM with MA D stated she knew she was not supposed to carry dose cups of medication by placing one finger on inside of cup and thumb in another dose cup (MA D made a pinching motion with thumb/index finger). MA D stated she had a tray, somewhere, for the purpose of carrying medication but failed to use tray because she was in a hurry and just didn't think of using tray. MA D stated she could have contaminated dose cups with germs and caused resident to become sick. MA D stated she had been in-serviced on Infection Control many times by various nurses. MA D stated only dose cup sides should be touched to prevent cross contamination. Interview on 12/13/22 at 10:15 AM with ADON A stated the inside of dose cups should not be touched, that it was cross contamination. ADON A stated all nursing staff was in-serviced to never touch inside of dose cups because that was contamination and had the potential to cause resident illness. 676104 Page 4 of 6 676104 12/14/2022 Grapevine Medical Lodge 1005 Ira E. Woods Parkway Grapevine, TX 76051

F 0880 Interview on 12/13/22 at 10:19 AM with ADON B stated medication cups should only be touched on Level of Harm - Minimal harm or potential for actual harm outside of container, away from container lip; stated touching inside of container could cause resident illness. Residents Affected - Few Interview on 12/13/22 at 1:43 PM with the Administrator of MA D picking up dose cups (containing medication) using thumb and forefinger, with one digit grasping inside of cup and 2nd digit grasping outside of cup. Administrator stated he did not know all of the nursing processes; that he left that part to the DON. The Administrator stated staff was being in-serviced on proper procedure. Interview on 12/13/22 at 3:00 PM with the DON stated all nurses/med-aides were inserviced to only touch med cups on outside of cups. DON stated grasping dose cups with one digit on the inside of the pill cup was contamination and should not occur. The DON stated RN H in-serviced medication-aides and nurse aides on Infection Control. The DON stated RN L had in-serviced all nurses yesterday on Infection Control with return demonstration. Record review of the policy Infection Prevention and Control dated August 2016 revealed . 7. Prevention of Infection 3. educating staff and ensuring that they adhere to proper techniques and procedures. www.dhhs.ne.gov/schoolhealth Summary of 14 Areas of Competency for Medication Administration by Unlicensed Assistive Personnel 1. Recognize the recipient's right to personal privacy. 2. Recognize the recipient's right to refuse medication. 3. Maintain hygiene and standards of infection control. 4. Follow facility procedures regarding storage, handling, and disposal of medications. 5. Recognize general conditions when the medication should not be given. 676104 Page 5 of 6 676104 12/14/2022 Grapevine Medical Lodge 1005 Ira E. Woods Parkway Grapevine, TX 76051

F 0880 6. Accurately document all medications: Student name, medication name, dose, route, Level of Harm - Minimal harm or potential for actual harm time administered, or refusal. 7. Follow the Five Rights: Residents Affected - Few a. Right Person b. Right Medication c. Right Time d. Right Dose e. Right Route f. A sixth right is documenting the five rights of medication administration 676104 Page 6 of 6