Health inspection·December 4, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 of 6 residents (Resident #37 and Resident #50) reviewed for care plans. The facility did not update Resident #37's care plan to reflect goals and interventions for Hospice. The facility did not update Resident #50's care plan to reflect goals and interventions for Hospice. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs. The findings were: Review of Resident #37's MDS significant change assessment dated [DATE], reflected he was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: Dementia (confusion), hypertension (high blood pressure), and diabetes (high blood sugar). She had a BIMS score of 2 which reflected his cognitive status was severely impaired. She required moderate to maximum assist of one staff member for activities of daily living. Section O of the MDS was marked for hospice. Record review of Resident #37's Care Plan initiated on 04/011/23 reflected, it had been edited/updated on 09/30/2024, [resident was on hospice services], further review reflected there was no goals and approaches for hospice. Record review of the consolidated physician orders dated 11/2024 reflected Resident #37 admitted to Hospice services on 09/18/2024. Review of Resident #50's MDS quarterly assessment dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included: Hypertension (high blood pressure), and dementia (confused). Her BIMS score of 3 reflected her cognitive status was severely impaired. She required moderate to maximum assist of one staff member for activities of daily living. Section O of the MDS was marked for hospice. Record review of Resident #50's Care Plan initiated on 06/24/24 reflected, the care plan had been edited/updated on 9/10/2024, [resident was on hospice services], further review reflected there was Page 1 of 6 676128 676128 12/04/2024 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0657 no goals and approaches for hospice. Level of Harm - Minimal harm or potential for actual harm Record review of the consolidated physician orders dated 11/2024 reflected Resident #50 admitted to Hospice services on 07/24/2024 . Residents Affected - Some In an interview on 12/04/24 at 9:30 a.m. the DON revealed, the MDS/care plan nurse should be aware of any changes with the residents and update the plan of care. The DON stated that they did not have permanent MDS coordinator nurse, the floater MDS nurse for the cooperation was coming when she could and completing the MDS, but not updating any plans of care. The DON stated that she and the ADONs were updating the plan of care. The DON stated that she supposed there had been some of the plan of care's that had not been updated appropriately with the goals and approaches. The DON was aware that Resident #37 and Resident #50 were on Hospice services. The DON stated if the care plans were not follow-up on appropriately then the staff would not know what the goals are. In an interview on 12/04/24 at 12:00 p.m. the Administrator revealed the MDS/care plan nurse position was open at this time and the facility was looking for a new one. The Administrator stated he was aware the MDS was being completed by the floating MDS nurse for the company. He was unclear who was following up on the care plans. Review of the facility's policy titled Care plan Process and Person-Centered Care dated March 2022, reflected the following: 7.The comprehensive, person-centered care plan: a. incudes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the residents' highest particle, physical, mental, and psychosocial well-being .c. incudes the resident's goals .11. Assessments of the residents are ongoing and care plans are revised as information about the residents and the resident's condition change .12. the interdisciplinary team reviews and updates the care plan; a. when there is a significant change in the residents' condition; b. when the desired outcome is not meet. 676128 Page 2 of 6 676128 12/04/2024 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for three (Residents #22, #36, and #59) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #22, #36, and #59. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #22's significant change MDS assessment, dated 09/21/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hypertension (high blood pressure), dementia (confusion), and diabetes (high blood sugar). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #22's plan of care dated 09/21/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 12/02/2024 at 12:30 p.m., revealed Resident #22 was sitting in her wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There was dried food substances on the back of the wheelchair and both wheels. Review of Resident #36's quarterly MDS assessment, dated 10/28/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), muscle weakness (muscle deterioration), and age-related physical debility (no balance). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident 36's plan of care dated 09/04/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation on 12/02/24 at 12:45 p.m., revealed Resident #36 was sitting in her wheelchair in the dining room and the wheelchair's left armrest was cracked with exposed foam and the right arm rest was missing. There were no skin tears on arms. The wheels of the wheelchair had dried food substance on both wheels and on wheel rims and there was dried food on the seat and back of the wheelchair. Review of Resident #59's quarterly MDS assessment, dated 11/20/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of atrial Fib (heart rate is irregular) hypertension (high blood pressure), and Alzheimer's dementia (confusion). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #59's updated plan of care dated 10/21/2024 with updates reflected goals and 676128 Page 3 of 6 676128 12/04/2024 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0689 approaches to include wheelchair mobility. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 12/02/2024 at 12:47 p.m ., revealed Resident #59 was sitting in her wheelchair in the dining room and the wheelchair's left armrest was cracked with exposed foam. There were no skin tears on the arms. Resident #59 stated she was just fine, and she thought her wheelchair was fine also, she did not need another wheelchair of new arms. Residents Affected - Some In an interview on 12/04/2024 at 10:30 a.m., MA A stated when a resident's wheelchair needed repair the staff were to report it to the maintenance director. MA A stated we report to the maintenance director by writing in the book at the nurse station. MA A was unaware of any wheelchair that required repair, even though she did served lunch in the dining room and saw all the residents. In an interview on 12/04/2024 at 10:59 a.m. with the DON revealed she had no cleaning schedule for wheelchairs. The DON stated if the wheelchairs were dirty the night shift would clean them if they saw them, there was no monitoring system for cleaning the wheelchairs, it was on an as needed basis. The DON stated if there were many dirty wheelchairs, then [we] (administrative staff) would power wash the wheelchair . The DON stated if the wheelchairs were left in bad repair and were not clean, it could affect the quality of life for the residents. In an interview and record review on 12/04/2024 at 11:00 a.m., the with Maintenance Director revealed the staff informs him of equipment repair by logging the needed repair in the maintenance book at the nurse's station . The Maintenance Director verified he was the person who repaired the wheelchairs, but he was unaware of any wheelchairs that required new armrest. Record review at the nurses' station of the maintenance logs reflected no wheelchairs that had been placed in the log for repairs. In an in interview on 12/04/2024 at 12:00 p.m., with the Administrator revealed he was not aware of any wheelchairs that required repair in the facility. The Administrator stated there were plenty of parts and he would see that the wheelchairs were repaired. Review of the Facility's Policy titled Maintenance services dated December 2009 reflected Maintenance service shall be provided to areas of the building, grounds, and equipment . f. establishing proprieties to providing repair services . j. others that may become necessary or appropriate .3. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner 676128 Page 4 of 6 676128 12/04/2024 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

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 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 the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were accurately labeled and dated with the received or expiration date. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the walk-in refrigerator on 12/2/2024 at 9:18 am revealed the following: -1 large zip top bag of lettuce with no received date or expiration date. - 1 large container of unidentified food sauce dated 12/1/24. There was no label description. -1 large container of unidentified yellow dessert dated 12/1/24. There was no label description. Observation of the dry storage on 12/2/2024 at 9:25 am revealed the following: -1 10lb bag of potatoes opened with no received date or expiration date. Interview with DM on 12/2/2024 at 9:50am, he stated staff is expected to label and date all foods stored in the refrigerator, freezer, or dry storage. He stated the risks of the foods and liquids not being properly labeled and dated could cause food borne illness, and individuals could become sick. Interview with DA B on 12/2/2024 at 11:38am, she stated any items stored in the refrigerator, freezer, or dry storage should be labeled and dated with an open date or expiration date. She stated the risks of foods not being labeled and dated could result in residents being served expired foods. Review of the facility's Food Receiving and Storage Policy, dated March 2019, reflected Policy Statement: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored , prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 4. All food items should be dated with the received date, unless labeled with a readable label from the food vendor. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial 676128 Page 5 of 6 676128 12/04/2024 The Madison on Marsh 2245 Marsh LN Carrollton, TX 75006

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov 676128 Page 6 of 6