Health inspection·March 29, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm -One box of navy beans opened revealing no plastic bag lining and without a secure fitting closure or covering. Interview on 3/27/2023 at 9:45am with Culinary Service Aide indicated he did not have an answer for why some of the boxes did not have received and or expiration dates. Residents Affected - Some Interview on 3/27/23 at 9:53am with the Chef indicated he did not have an answer for why products did not have received and or expiration dates. Chef stated if they received dented/damaged product or expired product, the product returns with delivery driver from the food service provider. Chef was unable to locate the schedule for cleaning the equipment. Chef stated if a dish cleaning machine broke, he would contact the product's manufacture representative to request service. Per the chef the 3- compartment sink would be utilized to wash dishes until the machine is fixed. Interview at 9:15am on 2/29/23 with Administrator and Culinary Services Director indicated they were unaware of any labeling, dating or expired food. Surveyor showed pictures of the round bulk [NAME] and bulk [NAME] rice expiration dates. Administrator and Culinary Service Director indicated they were unaware of the open boxes of green split peas and navy beans with no way to securely close the boxes. Interview on 3/29/23 at 11am with Culinary Services Director provided Food Storage charts used to determine expiration dates along with a Safe Food Handbook from USDA United States Department of Agriculture. Culinary Services Director indicated she contacted the food service provider for the green split peas and navy beans, and they were unaware the box did not have the customary bag liner. Culinary Service Director indicated the food service provider will replace the boxes with ones that have the bag liner. Culinary Services Director indicated the kitchen staff had 24/7 access to the food storage charts used to determine expiration dates. Interview on 3/28/23 at 11:45am with Clinical Nutritional Coordinator indicated the schedule for cleaning the equipment was on her desk. Clinical Nutritional Coordinator also indicated she kept forms indicating the expiration dates for the foods that do not come with an expiration date on the package. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Review of the Food and Drug Administration Food Code, dated 2017, reflected, Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676135 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presbyterian Village North Special Care Ctr 8600 Skyline Dr Dallas, TX 75243 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #48) observed for infection control. Residents Affected - Few CNA A failed to perform hand hygiene while providing incontinence care to Resident # 48. This failure could place the residents at risk for infection. Findings include: Record review of Resident #48's face sheet dated 03/29/23 reflected he was [AGE] years old male. He was admitted to the facility on [DATE]. He was admitted with dementia, chronic kidney disease, bipolar disease, heart failure, low back pain mad muscle diagnosis. Review of Resident #48 's care plan initiated 03/24/23 reflected Resident #48 had elimination risk as evidence by urinary/bowel incontinence related to mixed incontinence. Further reflected for intervention, to check the resident for incontinence, wash, rinse, and dry perineum (the area between the anus and the scrotum or vulva). Observation on 03/28/23 at 12:00 PM revealed CNA A providing incontinent care to Resident #48. CNA A was observed completing hand hygiene before care, then she informed the resident she was providing incontinent care. CNA A then left the room and stated she was going to get some items and then she came back, completed hand hygiene, and gloved. CNA A positioned the resident and unfastened the brief and proceeded to clean Resident #48's front area with wipes and then she completed hand hygiene. CNA A then positioned the resident on the side and cleaned the resident's bottom area. After cleaning the resident CNA A took off the dirty brief and without any form of change of gloves or hand hygiene, CNA A applied the clean brief and then completed hand hygiene. In an interview on 03/28/23 at 12:24 PM with CNA A she stated she was to wash hands before and after care. CNA A also stated she was supposed to change gloves and complete hand hygiene after taking the residents dirty brief off. CNA A stated she did not complete hand hygiene or change gloves after cleaning the resident because she was moving too fast, and she forgot. CNA A stated she was supposed change gloves and complete hand hygiene to prevent the spread of infection. CNA A stated she had an in-service on infection control about two weeks ago. In an interview on 03/28/23 at 03:00 PM with the DON she stated during incontinent care the staff were to complete hand hygiene before and after care. DON also stated in between care CNA A was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread on infection. The DON provided an in-service on hand hygiene/infection control dated 01/24/23 that the facility had completed with the staff. Inservice was reviewed. Review of the facility policy revised August 2019, titled handwashing/hand hygiene reflected, This facility considers hand hygiene the primary means to prevent the spread of infection.6. Use an alcohol-based hand rub . or, alternatively, soap .and water for following situations: .h. Before moving from contaminated body site to a clean body site during resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676135 If continuation sheet Page 3 of 3