Health inspection·May 11, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality for one (Resident #39) of 17 residents reviewed for resident rights. The facility failed to ensure MA C respected Resident # 39's wishes for him to wait before entering resident's room. This failure placed residents at risk of feeling disrespected and having their request unheard. Findings included: Review of Resident #39's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had a BIMS score of 15 which indicated she was cognitively intact, had clear speech and was able to express ideas and wants both verbal and with non-verbal expressions. Active diagnoses included diabetes, anxiety, and depression. During an interview on 05/10/23 at 3:25 p.m. with Resident #39 in her room, MA C was observed knocking on the resident's door and entered the room. Resident #39 asked MA C to please come back and stated, I am talking with someone very important, MA C continued coming into the room and stated, I just have to tell your roommate something, MA C proceeded past Resident #39 and went to speak with the roommate. Resident #39 frowned and stated, that irritates me so much, MA C left the room and shut the door. Approximately 5 minutes later, MA C once again knocked on the door and entered the room. Resident #39 once again asked if he would wait. MA C continued into the room and handed Resident #39 her medications with a cup of water. Resident # 39 took the medications, and stated to MA C, this could have waited, MA C continued to stand by the resident until she had taken her medications, and then left the room. Resident #39 stated she felt very frustrated and felt the staff does not listen to her and the other residents and felt disrespected. In an interview with MA C on 05/10/23 at 3:35 p.m., he stated he did not hear Resident #39 ask him to come back when he first entered the room to speak to the roommate. When asked about the second time he entered the resident's room with her medication and she asked him to come back, he stated the resident was very adamant about getting her medications on time so he felt it was important for him to come in and give her medications so they would be on time. In an interview with the Administrator on 05/10/23 at 3:40 p.m. she stated the staff were to always Page 1 of 20 676146 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respect the resident's wishes if they asked for them to wait before entering their rooms. She stated MA C should have stepped out of the room when the resident had asked him both times to wait and come back. She stated this was the Resident's home and the staff should respect the resident's wishes. In an interview with the DON on 05/11/23 at 9:00 a.m. she stated it was the expectation for all staff to respect the residents wishes. She stated MA C should have left the resident's room when she asked him to come back. She stated by ignoring the resident's request could make them feel disrespected. Review of the facility's policy titled, Resident Rights, dated February 2021, reflected, Employees shall treat all resident with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .be treated with respect, kindness, and dignity .exercise his or her rights without interference, coercions, discrimination, or reprisal from the facility . 676146 Page 2 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 ensure residents had the right to be fully informed of his or her total health status, including but not limited to, his or her medical condition for 1 (Resident #50) of 24 residents reviewed for residents' rights. Residents Affected - Few The facility failed to ensure Resident #50 was informed of his x-ray results on 05/01/23 and 05/03/23. The failure could place the residents at risk of not being to make informed decisions regarding their care. Findings included: Record Review of Resident #50's face sheet dated 05/11/23 reflected he was an [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses which included dementia, respiratory failure, diabetes, heart failure, and heart disease. Record Review of Resident #50's Annual MDS assessment dated [DATE] reflected Resident #50 was cognitively intact with a BIMS score of 15. He required extensive assistance for most ADLs except eating was supervision only. Resident #50 was frequently incontinent of bowel. Record Review of Resident #50's Comprehensive Care Plan with a start date of 10/10/22 and last revised 05/11/23 reflected Resident #50 was at risk for complications related to constipation and decreased mobility. Interventions included daily exercise and mobility as tolerated to promote gastric mobility; encourage resident to sit on toilet to evacuate bowels if possible, monitor medications for side effects of constipation. Keep physician informed of any problems; Monitor/document/report PRN [signs and symptoms] of complications related to constipation .; and record bowel movement pattern each day. Describe amount, color and consistency. Record Review of Resident #50's KUB (Kidney, Ureter, Bladder) X-ray dated 05/01/23 indicated findings suggestive of moderate constipation and dilated bowel visualized in the abdomen. Follow-up was suggested. Facility was notified at 05/01/23 at 13:25 of x-ray findings. Record Review of Resident #50's Progress Note by LVN I dated 05/01/23 indicated physician was notified of KUB (results with new medication orders. KUB scheduled for 05/03/23. It did not reflect Resident #50 was notified of results and new orders. Record Review of Resident #50's Progress Notes for May 2023 reflected no documentation of KUB x-ray dated 05/03/23 findings. It did not reflect Resident #50 was informed of KUB x-ray results. There were no progress notes for 05/03/23. Record Review of Resident #50's KUB (Kidney, Ureter, Bladder) X-Ray dated 05/03/23 indicated the x- ray revealed no evidence of obstruction with no significant findings and normal bowel gas pattern. Interviews on 05/10/23 at 11:00 AM with Resident #50 revealed he had not received his x-ray results from the facility and had asked to see his medical records. 676146 Page 3 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/11/23 at 9:31 AM with Resident #50 revealed he had asked to know his x-ray results of his KUB to one of the nurses and to see his medical record. He stated he had asked to see his physician but had not seen a physician since his last KUB was completed. He could not recall which nurse he had talked to about it. Interview on 05/11/23 at 9:29 AM with LVN G revealed Resident #50 had mentioned to him that past Monday (05/08/23) about issues of not pooping. He stated he followed up with CNA who informed him that Resident #50 did have a bowel movement that day. He stated he was working on 05/03/23 with LVN I but did not go over KUB results with Resident #50 on their shift. He stated he did not inform Resident #50 of any of his KUB results nor was he asked about them. He stated the KUB results for Resident #50 did not come in on his shift. He stated he had not been asked by Resident #50 to see his medical records. Interview on 05/11/23 at 9:50 AM with the Weekend Supervisor revealed Resident #50's KUB results came in on 04/29/23 and she did share the results with Resident #50 and his physician. She stated she was not working on 05/01/23 or 05/03/23 when the other KUB results came in. She stated last weekend Resident #50 did not mention to her about wanting to see his physician or asking about his KUB results. She stated Resident #50 liked to be informed of any issues with his medical conditions along with medication changes and was very concerned about his bowel movements. The Weekend Supervisor stated Resident #50 was his own responsible party and preferred to be informed first of any issues. She stated Resident #50 had not mentioned to her about wanting to see his medical records and if he asked her she would provided the requested medical records to him. Interview on 05/11/23 at 10:20 AM with LVN I revealed he could not recall if he was working when KUB results came in on 05/01/23 but if he did a nursing note on 05/01/23 indicating he was notified of Resident #50's x-ray results then he also would have notified Resident #50. He stated he did not recall speaking with Resident #50 about his KUB results on 05/03/23 and could not remember if the KUB results came in on his shift. He stated Resident #50 did not mention to him about wanting to see his medical records or to see his physician. Interview on 05/11/23 at 4:24 PM with LVN F revealed she was not working on 05/01/23 or 05/03/23 when x-ray results were received for Resident #50. She stated Resident #50 was his own responsible party and spoke with him about any medical concerns not resident's wife. She stated she was not aware of Resident #50 wanting to see his physician or his medical records. She stated resident had the right to view his medical records. She stated she thought LVN I spoke to Resident #50 about his KUB results on 05/01/23. Interview on 05/11/23 at 11:30 AM with Resident #50's Physician revealed she was notified by facility nurse about Resident #50's KUB results which were also sent to her on 05/03/23 with no significant findings to indicate any issues and thought it was LVN I who informed her of the KUB results. She stated she had not visited with Resident #50 since the last time. She stated the last time she visited with Resident #50 was on 04/29/23 when he complained of not having a bowel movement so she ordered the first KUB on 04/29/23. She stated she had not been informed Resident #50 requested a visit from physician and would visit resident when she was next in facility. Interview on 05/11/23 at 2:13 PM with Admin revealed she would expect nurses to review x-ray results with resident and/or responsible party. She stated she was not aware or certain if Resident #50 had requested his medical record. She stated if a resident requested medical records they would provide them as resident has right to ask for medical records. She stated if a responsible party or family 676146 Page 4 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few member requested medical records they would first need to fill out a form for request for medical records before the facility could process their request. Review of facility's policy Resident Rights revised February 2021 reflected Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .o. be notified of his or her medical condition and of any changes in his condition; p. be informed of, and participate in, his or her care planning and treatment; q. access personal and medical records pertaining to him or herself . 676146 Page 5 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for two (03/28/23 and 04/25/23) of three Resident Council meetings reviewed for resident group response. Residents Affected - Some The facility failed to ensure prompt efforts were made by the facility to resolve grievances of the confidential Resident Council reviewed for grievances. This failure could place facility residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: Record review of the Resident council meeting for March 2023 and April 2023 reflected no issues or concerns with Administration, Nursing, Dietary, Environmental Services, Social Services, Rehab Services, Trust Fund, Housekeeping Services, and the Activity Department. The Residents who had participated in the Resident Council meeting were not identified. Record review of the Grievance logs for March 2023 and April 2023 did not reflect any Grievance filed on behalf of the Resident Council. In an interview with Resident #28, the current Resident Council President on 05/10/23 at 02:45 p.m., she stated the council never received any response back from the facility about concerns they had brought up on behalf of the Resident Council for several months. She stated the previous Activity Director used to type up the council minutes and bring them to her for her to sign off on. She stated she had not received a copy of the minutes since the current Activity Director had started taking the minutes for them. She stated she was not at the council meeting in April 2023 due to illness, but stated she recalled in March 2023, the council was complaining about the noise in the hallways around 6:00 a.m. and during breakfast serving time. She stated she was sure there were more things, but this was the only thing she could remember at this time. She stated the facility had never informed them what they were doing to address those concerns. In an interview with Resident #39 on 05/10/23 at 3:25 p.m. she stated she participated in the Resident Council meetings in March 2023 and April 2023. She stated they had not gotten any feedback from Administration about the issues that had been brought up. She stated the main issues, she could recall, was still ongoing, was how loud the staff was in the hallway in the early morning hours from about 6:00 a.m. up till around noon. She stated some of the residents liked to sleep in in the mornings and can't because of the noise. She stated they used to get copies of the minutes of the meetings, but stated since the new Activity Director had started, they had not gotten any copies of the minutes, or any feedback on what the facility was doing to resolve their issues. In an interview with the facility's appointed Ombudsman's on 05/10/23 at 12:15 p.m. she stated she was shocked there were no grievances documented from the Resident Council meeting she had attended in April 2023. She stated she recalled the residents complaining about how loud the staff were in the hallways and stated there had been some issues with someone's mail being opened. She stated the Activity Director was a seasoned Activity Director and assumed she was taking the council's concerns to Administration so they could be resolved. She stated the Resident Council president had stated to 676146 Page 6 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her she was not getting copies of the minutes from the meetings and had planned to request those in the upcoming meeting. In an interview with the Activity Director on 05/10/23 at 01:15 p.m. she stated she was responsible for taking the minutes for the resident council meetings. She stated she had worked at the facility for about 7 months but stated she had been an Activity Director at previous facilities and had also performed that function in her previous jobs. She stated if the council had grievances, she was supposed to document those grievance and bring them to Administration for them to resolve. When asked about the Resident Council minutes for March and April of 2023, she stated she did not feel the issues the residents had brought up rose to a Grievance level. She stated she recalled one of the members complained about some missing clothing, which she stated she went to the laundry to try and find. She stated 2 residents complained about their mail being opened and she went and told the business office manager. She stated she also recalled them complaining about the loud staff on the hallway and she went and told the charge nurse. She stated she had assumed it had all been taken care of. She stated she was not sure if the issues had been resolved or not. In an interview with the Administrator on 01/13/22 at 11:50 a.m., she stated the Activity Director had been appointed to take the minutes of the Resident Council meetings. She stated it was her responsibility to document any concerns brought forward by the council and bring it to the morning stand up meetings the day after the council meeting. She stated if there were concerns then the department head responsible for the area of concern are assigned to the concern and address the problem and get back with the individual who had the concern or the group if it were a group concern. She stated she had asked the Activity Director after each Resident council meeting if there were any concerns and had been told there were none. She stated failing to bring issues to the Administration could result in residents feeling unheard and issues not being addressed and resolved. Review of the facility's policy titled Grievances/Complaints, filing reflected, Residents and their representative have the right to file grievance, either orally or in writing, to the facility staff or to the agency designated to hear grievances .The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility .All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response .Upon receipt of a grievance and /or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five(5) working days of receiving the grievance and /or complaint .The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct and identified problems The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision . 676146 Page 7 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #48, Resident #56) of 8 residents reviewed for ADLs. Residents Affected - Some The facility failed to ensure: 1-Resident #48 had her fingernails trimmed. 2-Resident #56 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1-Review of Resident #48's Comprehensive MDS assessment dated [DATE] reflected Resident #48 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses include type 2 diabetes, lack of coordination, and muscle weakness. Resident #48 had a BIMS of 08 which indicated Resident #48's cognition was moderately impaired. She required extensive assistance of two-persons physical assistance with transfers, toilet use, and personal hygiene. Review of Resident #48's Comprehensive Care Plan, revised 05/11/23, reflected the following: Problem: Resident has an ADL self-care performance deficit. Goal: Resident will improve the current level of function through the review date. Interventions: Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. An observation and interview on 05/09/23 at 10:19 AM revealed Resident #48 was sitting in her wheelchair, watching TV in her room. The nails on both hands were approximately 0.5 centimeter in length extending from the tip of her fingers. The second fingernail, on both hands, were chipped. The middle fingernail on the left hand was chipped. Resident #48 did not remember if she asked staff to cut her fingernails, and she did not remember when was the last time her finger nails were cut. 2-Review of Resident #56 Comprehensive MDS assessment, dated 03/24/2023, reflected Resident #56 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included lack of coordination, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle weakness. Resident #56 had a BIMS of 08 which indicated Resident #56's cognition was moderately impaired. Resident#56 extensive assistance of one-persons physical assistance with transfer, toilet use, and personal hygiene. Review of Resident #56's Comprehensive Care Plan dated 05/11/23 reflected the following: Focus: resident#56 has an ADL self-care performance deficit related to activity intolerance, dementia. Goal: the resident will maintain current level of function through the review date. Interventions: Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation and interview on 05/09/23 at 10:49 AM revealed Resident #56 was laying in his bed. The 676146 Page 8 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nails on both hands were approximately 0.3 cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #56 was confused unable to answer questions. Interview on 05/09/23 at 1:51 PM, CNA D stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA D stated she did not notice the nails of resident #48 and #56. CNA D stated she would clean and trim Resident #56's nails right then. CNA D stated she would talk to the nurse about Resident #48 because she was diabetics. Interview on 05/09/23 at 2:02 PM, LVN E stated CNAs were responsible to clean and trim residents' nails during the showers. LVN E stated only nurses cut residents' nails if they were diabetic. LVN E stated no one notified her Resident #48's nails were long and chipped, and she had not noticed the nails herself. LVN E stated Resident#48 was diabetic she would clean and trim her nails. LVN E stated she will ask CNA D to clean and trim Resident #56's finger nails because he was not diabetic. Interview on 05/11/23 at 11:13 AM, the DON stated nail care should have been completed as needed and every time aides wash the residents' hands. The DON stated nails should have been observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. The DON stated she was responsible to do routine rounds for monitoring. Record review of the facility's policy titled Fingernails/Toenails, Care of, revised February 2018, reflected The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 676146 Page 9 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #5) of two residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #5 after an incontinent episode when she failed to wipe from the base of the labia towards and extending over the resident's buttocks. This failure placed residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Review of Resident #5's Quarterly MDS assessment dated [DATE], reflected a [AGE] year-old female with an admission date of 05/10/21. Resident #5 had a BIMs of 15 which indicated she was cognitively intact. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Her diagnoses included septicemia (bacteria in the blood from a severe infection) cerebrovascular accident (stroke), dementia, and morbid obesity. Review of Resident #5's care plan revised on 05/11/23 reflected, . [Resident #5] has bladder incontinence .Goal .will remain free from skin breakdown due to incontinence and brief use .Intervention .Staff will check at least every 2 hours and as required for incontinence Staff to clean peri-area with each incontinence episode. An observation on 05/09/23 at 03:20 p.m. revealed the Staffing Coordinator, CNA A and CNA B in Resident #5's room preparing to provide incontinence care. All staff washed their hands and put on gloves. Staffing Coordinator unfastened Resident #5's brief to reveal the resident had been incontinent of urine. Staffing Coordinator removed the soiled brief and placed it in the trash can, removed her gloves and washed her hands, and left the room to retrieve a clean gown. CNA A took a peri- wipe and cleaned residents' perineal area, wiping from front to back. With the assistance of CNA B, Resident #5 was rolled onto her left side. CNA A took a peri- wipe and wiped each of the residents' buttocks from her lower back down toward the resident's labia. She then took another wipe and wiped from the residents lower back down her rectal area toward the resident's labia and perineal area. Staffing coordinator returned to the room, washed her hands, and applied gloves and applied barrier cream to the residents' buttocks and assisted the resident back onto her back and fastened the brief. All staff removed their gloves and washed their hands. Review of CNA A's skill checks dated 01/25/23 reflected she was competent in performing peri-care. In an interview with CNA A on 03/01/23 at 10:15 a.m. she stated she was supposed to clean from front to back. She stated she should have cleaned the resident's rectal area opposite of what she had done. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them a risk of infections. In an interview with DON on 05/11/23 at 09:05 a.m. she stated staff were to clean residents from 676146 Page 10 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few front to back during incontinence care. She stated by not following proper peri care it placed residents at risk of urinary tract infections. Review of the facility's policy titled, Perineal care, revised February 2018, reflected, .Wash and dry hands thoroughly .put on gloves .wash perineal are, wiping from front to back .Separate labia and wash area downward from front to back Ask the resident to turn on her side .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly . 676146 Page 11 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0695 Provide safe and appropriate respiratory care for a resident when 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 that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #42) of one resident reviewed for tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. Residents Affected - Few The facility failed to ensure LVN G followed the procedure for tracheostomy care for Resident #42 on 05/10/23 by: 1. Maintaining a sterile/clean field for supplies necessary for care 2. Changing his gloves and performing hand hygiene before applying a clean trach drainage sponge 3. Using sterile technique when inserting the inner cannula into the resident's trach. These failures could place residents at risk for respiratory infections. Findings include: Review of Resident #42's Comprehensive MDS assessment, dated 04/16/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS was 99 which mean Resident #42 was unable to complete the assessment interview. His active diagnoses included chronic respiratory failure with hypoxia (absence of oxygen), tracheostomy status and hemiplegia (paralysis of one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side. In Section O-Special Treatments, Procedures, and Programs it revealed he required tracheostomy (trach) care during the 14 days look back period. Review of Resident #42's care plan dated 04/14/23, reflected, [Resident #42] is at risk for infection related to frequent suctioning from his tracheostomy. Goals- . Resident #42 will show no signs/symptoms of infection. Interventions . Educate [Resident #42]/representative on infection control practices. Staff to follow standard precaution, including proper hand washing technique, to minimize microorganism transmission . Review of Resident #42's Consolidated Physician's orders dated May 2023, reflected, .Tracheostomy care every shift and as needed. In an observation on 05/10/23 at 7:45 AM revealed LVN G finished administering medication through G-tube (a surgically placed device used to give direct access to the stomach for feeding, hydration, or medicine) to Resident #42. LVN G removed dirty gloves and donned clean gloves without performing hand hygiene. LVN G removed and discarded the tracheostomy stoma dressing. Without changing gloves, LVN G opened tracheostomy kit and placed it on a bedside table. LVN G removed and discarded the dirty gloves and donned gloves from the tracheostomy kit without performing hand hygiene. LVN G poured normal saline on the kit's tray. LVN G then removed the inner cannula from inside the resident's tracheostomy, revealing the tube was coated in dark brown substances, and cleaned it with the normal saline and a brush. Wearing the same gloves, LVN G then picked up the cleaned inner cannula and inserted it into the trach and locked it. LVN G removed and discarded the dirty gloves and opened another 676146 Page 12 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tracheostomy kit. LVN G then washed hand and donned sterile gloves. LVN G attached the suction to the resident's in-line suction line and inserted the suction line into the trach 3 times. LVN G then cleared the line and turned off the suction machine. LVN G removed and discarded gloves and donned clean gloves without performing any kind of hand hygiene. LVN G wet the gauze with normal saline and wiped the stoma site with the wet gauze. LVN G then picked up the stoma drainage sponge and placed it around the tracheostomy tube while wearing the same gloves. LVN G then removed his gloves and washed his hands. In an interview with LVN G on 05/10/23 at 8:30 AM he stated he was supposed to perform hand hygiene before and after trach care. He stated he knew the procedure was supposed to be a sterile procedure to reduce the risk of cross contamination and stated he supposed to wear a sterile glove to inset the inner cannula. Review of LVN G's Competency checks for tracheostomy care reflected he was skills checked on 05/03/23 by ADON and deemed competent in trach care. In an interview with the DON on 05/11/23 at 11:13 AM revealed hand hygiene was to be performed anytime a staff member went from a dirty procedure to a clean procedure. She stated trach care was to be an aseptic/sterile technique. She stated failure for the staff to follow proper procedures could result in infections. Review of the facility's policy, Tracheostomy Care dated August 2013, reflected, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . General Guidelines: 1. Aseptic technique must be used: a. during cleaning and sterilization of reusable tracheostomy tube. Procedure Guidelines: Preparation and assessment: . 8. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. 9. Wash hands. Clean the Removable Inner Cannula . 11. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. 12. Soak the cannula in hydrogen peroxide/saline mixture. 13. Clean with brush. Rinse with saline and dry with pipe cleaners. 14. Remove and discard gloves into appropriate receptacle. 15. Wash hands and put on fresh gloves. 16. Replace the cannula carefully and lock in place. 676146 Page 13 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication carts (300 hall medication aide cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecured containers were immediately removed from stock. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 05/09/2023 at 2:50 PM of the Medication Aide Cart Hall 300 revealed the blister pack for Resident #118's trauma 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister. In an observation and interview on 05/09/23 at 2:50 PM, MA C stated the opened blister had 2 pills, he gave one early in the morning and the other pill would be given in the evening. MA C stated the old order was to give 2 pills every 6 hours as needed for pain. The order was changed to give 1 tablet by mouth every 6 hours. MA C stated since the medication was the same, we just put a change of direction sticker on the package, and we continue to give the medication. Interview and observation on 05/09/23 at 3:00 PM, LVN F stated she was unaware when the blister pack seal was broken. She stated if the order changed, she would send it to the pharmacist and get new medication with new directions. She stated the risk of a damaged blister would be a potential for drug diversion. At that time, the surveyor checked the medication; the count was compared to the blister pack and the count was correct. Interview on 05/11/23 at 11:13 AM, the DON stated if a blister pack medication seal was broken the pill should have been discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated if the order changed, nursing staff would send the new order to the pharmacy to get medication with the new directions. The risk would be losing the medication because the seal was broken and potential for drug diversion. Review of the facility's policy Medication Labeling and Storage, revised February 2023, reflected the following: .If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 676146 Page 14 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

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 review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items in dry storage were labeled and dated. 2. The facility failed to ensure 4 individual packets of yogurt in refrigerator was not expired. These failures could residents at risk for food contamination and food-borne illness. Findings included: Observations on 05/09/23 in Dry Storage area of kitchen revealed the following: at 10:26 AM revealed 9 packages of banana flavor dry mix was not in the original box and did not reflect an expiration date or a date when received. at 10:28 AM revealed powdered sugar in plastic bag was not dated. at 10:30 AM revealed a plastic container with individual ketchup packets about ½ full in plastic with no date when received. Interview on 05/09/23 at 10:33 AM with Dietary Manager revealed powdered sugar should be dated when opened and when received. He stated the individual ketchup packages were overflow, taken out of original box, and were received on 05/04/23 but there should have been a date on it when received. He stated dating the food items was important to know, so they could determine when items needed to be disposed of. Observation on 05/09/23 at 10:35 AM of walk-in refrigerator revealed 4 individual packets of strawberry and peach yogurt with use by date of 05/05/23. Interview on 05/09/23 at 10:37 AM with Dietary Manager revealed he would throw out the yogurt and should have been disposed of already. He stated there should not be expired food in the refrigerator. Review of facility's policy Food Production and Food Safety dated 2019 reflected under refrigerated food storage .f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of facility's policy Food Storage dated 2019 reflected Food will be stored, at appropriate 676146 Page 15 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0812 Level of Harm - Minimal harm or potential for actual harm temperatures and by methods designed to prevent contamination or cross contamination .Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat . Review of the US Food Code dated 2017 reflected under Labeling 3-602.11 Food Labels Residents Affected - Some (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 -Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement 676146 Page 16 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

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 three residents (Resident #42) observed for infection control. Residents Affected - Few The facility failed to ensure LVN G perform hand hygiene while administering medication to Resident # 42. This failure could place the residents at risk for infection. Findings include: Review of Resident #42's Comprehensive MDS assessment, dated 04/16/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS was 99 which meant Resident #42 was unable to complete the assessment interview. His active diagnoses included dysphagia (difficulty in swallowing), tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) status and hemiplegia (paralysis of one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, type 2 diabetes mellitus, and gastrostomy (a surgical procedure used to insert a tube through the abdomen and into the stomach) status. Review of Resident #42's care plan dated 04/14/23, reflected, [Resident #42] requires tube feeding related to dysphagia. Goals- . Resident #42 will remain free of side effects or complications related to tube feeding through the review date . Observation on 05/10/23 at 7:20 AM revealed LVN G administered morning medication to Resident #42. LVN G was observed washing hands and donning clean gloves. LVN G connected the intravenous tubing to the intravenous port on the right arm. LVN G changed gloves without performing hand hygiene. LVN G to check Resident #42 blood sugar, he inserted a test strip into the glucometer, he used the lancing device on the side of the Resident #42 fingertip to get a drop of blood. The blood glucose level was 129, revealed no need for insulin. LVN G removed and discarded the dirty gloves and he then donned clean gloves without performing any kind of hand hygiene. LVN G turned off the tube feeding pump and checked residual (the amount aspirated from the stomach following administration of enteral feed). It was 20 ml. LVN G changed his gloves without performing hand hygiene. LVN G administered the medication to Resident #42 through the tube. LVN G changed gloves without performing hand hygiene and then he proceeded to do trach care. In an interview on 05/10/23 at 8:30 AM with LVN G he stated he was to perform hand hygiene between change of gloves. LVN G also stated he was supposed to wash hands before he donned gloves to start trach care. LVN G stated he did not complete hand hygiene or change gloves because he was nervous. LVN G stated he was supposed to change gloves and complete hand hygiene to prevent the spread of infection. In an interview on 05/11/23 at 11:13 PM with the DON she stated it was the standard precautions to perform hand hygiene after removing gloves. The DON stated her expectations that staff were to complete hand hygiene after blood sugar check. The DON stated the staff were to complete hand hygiene before trach care to prevent the spread of infection. 676146 Page 17 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy revised September 2022, titled Standard Precautions reflected, . Standard precautions include the following practices 1. Hand hygiene. A. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub. B. Hand hygiene is performed with alcohol-based hand rub or soap and water: . 5) after removing gloves . Residents Affected - Few 676146 Page 18 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0908 Keep all essential equipment working safely. 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 residents' patient care equipment was in safe operating condition for two (Residents #39 and #19) of 24 residents reviewed for wheelchairs. Residents Affected - Some 1. The facility failed to ensure Resident #39's wheelchair was properly maintained. Resident #29's side arm cushions on both sides of her wheelchair were missing for a couple of months. 2. The facility failed to ensure Resident #19's wheelchair was properly maintained. Resident #19's right brake handle on his wheelchair was loose. These failures could place residents at risk for skin tears, falls, and injuries. Findings included: 1. Review of Resident #39's face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes, anxiety, hypertension, abnormalities of gait and mobility, physical debility (weakness), and generalized muscle weakness. Review of Resident #39's quarterly MDS assessment dated [DATE] reflected Resident #39 had a BIMS of 15 indicating she was cognitively intact. She required supervision to limited assistance with ADLs and ambulated in a wheelchair. Resident #39 had no falls since previous assessment. Observation on 05/10/23 at 11:15 AM and 3:15 PM revealed Resident #39's wheelchair had no cushion for arm railings showing the metal poles and a wash cloth was wrapped over middle of the arm railing with a string tied around the wash cloth. Resident #39's wheelchair arm railings had metal poles on both arm railings exposed about 2 inches in front of wash cloth and 2 inches behind wash cloth. Interviews on 05/10/23 at 11:15 AM and 3:15 PM with Resident # 39 revealed both sides of her wheelchair's arm cushions have been broken for a couple of months. She mentioned it happened on an outing and that the Activity Director witnessed the incident. Resident #39 stated she mentioned it to the Maintenance Director regarding the side arm cushions being broken but it had not been fixed yet. Interview on 05/10/23 at 3:26 PM with CNA H revealed she had not noticed Resident #39's wheelchair arm cushions were broken and Resident #39 had not mentioned to her about the wheelchair arm cushions needing to be fixed. She stated she worked Resident #39's hall about two to three times a week on the 2nd shift. Interview on 05/11/23 at 8:59 AM with Activity Director revealed she stated about a couple of months ago at an activity outing to store both of Resident #39's side cushions on her arm railings of wheelchair had come off. She stated the side cushions were already loose when they completely came off. She stated she wrote it in the Maintenance book about Resident #39's wheelchair but when looking through the Maintenance Log unable to find it. She stated some time after Resident #39's wheelchair arm railing's side cushions had come off in passing Resident #39 told her she had talked to Maintenance Director about it. She stated she had not followed up with Resident #39 or talked to Maintenance Director about it. 676146 Page 19 of 20 676146 05/11/2023 Town East Rehabilitation and Healthcare Center 3617 O'Hare Dr Mesquite, TX 75150

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interviews on 05/11/23 at 9:05 AM and 9:11 AM with Maintenance Director revealed the facility's maintenance log had only the resident room number and did not have a spot to put resident's name in the log. He stated the only wheelchair maintenance request he recalled for the last couple of months was for Resident #55 where he replaced the brakes on it. He stated he reviewed the maintenance log daily and put date resolved on it and initialed the repairs were completed. He stated that week was the first time he was informed of Resident #39's wheelchair needed to be repaired by the resident. He stated he had not had a chance to get to it yet but will repair it. He stated Resident #39 not having her side cushions on arm rest could cause skin tears. He stated not having a working wheelchair for a resident can place a resident at risk for falls. 2. Review of Resident #19's quarterly MDS assessment dated [DATE], reflected a [AGE] year-old male with an admission date of 08/15/2022. Review revealed resident #19 was cognitively intact with a BIMS score of 14. Resident #19 required one person assistance with transfers and used a wheelchair for ambulation. The resident's diagnosis included muscle wasting and atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue) and other abnormalities of gait and mobility. Interview on 05/08/2023 at 11:40 AM revealed Resident #19 had issues with his wheelchair and the facility staff had not repaired it even though he reported it to the Maintenance Director about a week ago. Observation and interview with Resident #19 on 05/10/2023 at 2:08 PM revealed his wheelchair's left brake handle was moving side to side when the brake handle was touched. Resident #19 stated the left brake handle of his wheelchair was loose and Resident #19 had reported this issue to the maintenance director a week ago. Observation of the Maintenance Director on 05/10/23 at 3:36 PM revealed he was inspecting the wheelchair of Resident # 19. Interview with the Maintenance Director on 05/10/23 at 3:40 PM revealed the right brake handle was loose. Record Review of Maintenance Log on 05/10/23 revealed on 05/09/23 room [ROOM NUMBER]A (Resident #39's room number) had a wheelchair which needed handle cushion repair. It was not resolved. Interview on 05/11/23 at 9:10 AM with Maintenance Director revealed Resident #19's wheelchair right brake was loose but operable. He stated residents not having a working wheelchair can place residents for fall risk. Review of facility's policy Work Orders, Maintenance revised April 2010 reflected Maintenance work orders shall be completed in order to establish a priority of maintenance service. The facility did not have a specific policy for wheelchairs per Maintenance Director on 05/11/23. 676146 Page 20 of 20