Health inspection·February 7, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 (Resident #35, #19, #39, and #4) of 4 residents checked for hot water temperatures. The facility failed to maintain hot water temperatures (100 - 110 degrees Fahrenheit) in the resident's bathroom sinks in both the short and long hallways. This failure could affect residents who had a bathroom by placing them at risk for infection, a decline in hygiene, low self-esteem, and a diminished quality of life. Findings include: Resident #35 Review of Resident #35's face sheet dated 02/07/23 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her primary admission diagnosis was Alzheimer's Disease. Review of Resident #35's Quarterly MDS dated [DATE] revealed her BIMS score was 11 (moderate impairment). In an interview and observation on 02/05/23 at 11:24 AM revealed Resident #35 was in room [ROOM NUMBER]B (short hallway). Resident #35 stated she did not have hot water in her sink in the bathroom. She stated, I would like to be able to wash my face with warm water. She stated it has been this way for a long time. She stated she reported it to staff several times, but it had never been fixed. The hot water temperature was checked. The water was allowed to run in the resident's sink for 2 minutes before the temperature was taken with a digital thermometer; the temperature registered at 70 degrees Fahrenheit. Resident #19 Review of Resident #19's face sheet dated 02/07/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. His primary admission diagnosis was senile degeneration of brain. Review of Resident #19's Annual MDS dated [DATE] reflected his BIMS score was 15 (no impairment). In an interview and observation on 02/06/23 at 10:20 AM revealed Resident #19 was in room [ROOM NUMBER]B (short hallway). Resident #19 stated he did not have hot water in his sink in the bathroom. Page 1 of 16 676148 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0584 Level of Harm - Minimal harm or potential for actual harm The resident stated, I would like to shave but I cannot due to not having any hot water. He stated it had been this way for a long time. He stated he reported it to staff several times, but it had never been fixed. The hot water temperature was checked. The water was allowed to run in the resident's sink for 2 minutes before the temperature was taken; the temperature registered at 70 degrees Fahrenheit. Residents Affected - Some Resident #39 Review of Resident #39's face sheet dated 02/07/23 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her primary admission diagnosis was cerebral infarction (stroke). Review of Resident #39's admission MDS dated [DATE] documented: Brief Interview Mental Status (BIMS) score 12 (moderate impairment). In an interview and observation on 02/06/23 at 11:45 AM revealed Resident #39 was in room [ROOM NUMBER]B (long hallway). Resident #39 stated her hot water was warm in her bathroom but it did not get hot. She said it had been that way since she had been at the facility. She stated she did not know if she had reported it to staff. The hot water temperature was checked. The water was allowed to run in the resident's sink for 2 minutes before the temperature was taken; the temperature registered at 80 degrees Fahrenheit. Resident #4 Review of Resident #4's face sheet dated 02/07/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. His primary admission diagnosis was Alzheimer's Disease with early onset. Review of Resident #4's Quarterly MDS dated [DATE] documented: Brief Interview Mental Status (BIMS) score 5 (severe cognitive impairment). In an interview and observation on 02/06/23 at 11:48 AM revealed Resident #4 was in room [ROOM NUMBER]A (long hallway) Resident #4 stated his water was warm but not hot in his bathroom. He stated he didn't know how long it had been this way. He stated he did not know if he had reported it to staff. The hot water temperature was checked. The water was allowed to run in the resident's sink for 2 minutes before the temperature was taken; the temperature registered at 80 degrees Fahrenheit. In an interview on 02/06/23 at 3:53 PM, the Interim Maintenance Director said he worked at other facilities and fills in as needed. He said the regulating valve on the hot water heater was not working when he checked on it this morning and ordered a new one today. He did not know how long it had not been working. He said it should come in next week. He said he tests the water temperatures in the facility when he is at the facility and they have all be within normal limits which between 100 degrees and 110 degrees Fahrenheit. He said he has not heard of any complaints from the residents about having no hot water in their bathrooms. In an interview on 02/07/23 at 10:10 AM, the Administrator said she was unaware residents did not have any hot water in their rooms. She said she had not received any complaints from the residents or staff. She said the facility had not had a maintenance director since November 2022, and 2 other maintenance staff from sister facilities had been filling in when needed. The Administrator stated the Interim Maintenance Director had been coming to the facility monthly. The Administrator stated a new Maintenance Director started this week, and he was getting familiar with the facility. She said 676148 Page 2 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she was going to fill out a grievance form and follow up on the matter. The facility policy was reviewed which revealed the water temperatures were to be checked daily. She said hot water temperature checks were completed and she would provide the temperature log documentation. In an interview on 02/07/23 at 10:24 AM, LVN E said she has worked both hallways in the facility. She was unaware the residents did not have any hot water in their rooms. She stated no residents had complained to her. In an interview on 02/07/23 at 10:30 AM, the DON said she had not received any complaints about the residents not having hot water in their rooms. In an interview and record review on 02/07/23 at 11:00 AM, the Administrator provided copies of hot water temperature checks. There was only one documented check for hot water temperatures in December 2022, on 12/05/22, and was not checked again until 01/13/22. Hot water checks were completed weekly for 3 weeks (not daily as per facility policy). On 02/07/23, only the kitchen hot water temperature was checked. The rest of the facility had no documented hot water temperature checks. The documentation failed to specify the exact room numbers that were tested except for the hallway for the dates listed above. The Administrator did not know where the temperature checks were taken that were documented. A record review of the Grievance Log and the Resident Council Minutes reviewed for the last 3 months, revealed no complaints from the residents related to not having hot water in in their rooms. A record review of the facility policy Hot Water Systems, dated 2003, revealed the following [in part]: 1. The hot water system will be check daily for temperature variations. 2. The temperature will be recorded on the water temperature log daily and maintained by the Maintenance Supervisor. 6. Water temperatures should be maintained between at 100 degrees Fahrenheit at a minimum, and 110 degrees Fahrenheit at a maximum. 9. Water temperatures will be taken daily. Take water temperatures in resident rooms at the beginning, middle, and the end of each water heater loop. Take temperatures in different rooms each daily to include all bed quarterly. 676148 Page 3 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

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 ensure residents unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for 1 (Residents #26) of 7 female residents for quality of care. Residents Affected - Few The facility failed to ensure Resident #26 who had excess facial hair had been shaved or oral care had been performed. This failure could place residents at risk for poor self-esteem and dental caries (also known as tooth decay or dental cavities). Findings included: Review of Resident #26's undated Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, hypertension (elevated blood pressure), malnutrition (decreased in weight and nutrition) and slowness in response. Review of Resident #26's MDS admission dated 12/03/2022 revealed she had a BIMS of 4 indicating she had significant cognitive impairment. Section G Functional Status revealed personal hygiene required one-person provide physical assistance. Review of Resident #26's Care Plan dated 12/07/2022 revealed: Focus: Resident #26 had oral/dental health problems due to poor oral hygiene and oral disease. Goal: Resident #26 will be free of infection pain or bleeding in the oral cavity Intervention: Provide mouth care as part of the ADL personal hygiene During initial tour on 02/05/2023 at 9:00 AM revealed Resident #26 was resting in bed lying on her back. Resident #26 had a thick beard and mustache. Resident #26 was not able to be interviewed at this time. During observation on 02/05/23 at 12:48 PM Resident #26 still had heavy facial hair. During an interview with Resident #26's family member, on 02/05/2023 at 1:40 PM revealed she had spoken to staff on several occasions about trimming Resident #26's chin hair. She stated the activity never occurred, so she (family member) had to do it herself. Resident #26's family member said she was concerned the staff did make Resident #26 the tooth brush assessible to brush her teeth. She said, there had been a couple of times the toothbrush was dry, and her breath smelled. During an interview on 02/05/2023 at 1:30 PM RN A said resident #26 refused to allow staff to trim her chin hair. During an interview on 02/06 at 2:10 PM LVN D said Resident #26 normally received assistance with shaving her face during her baths. She said she was given a bath every other day on Tuesday's, Thursday's, and Saturday's. She said she noticed Resident #26 needed her face shaved but CNAs were the 676148 Page 4 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ones that provide this care. LVN D said she should have been bathed and shaved on Saturday, but she noticed Resident #26 had a heavy beard. Review of Electronic Medical Record task on 02/06/2023 revealed Resident #26 did not have a bath. During an observation and interview on 02/07/2023 at 9:00 AM revealed CNA B was observed taking Resident #26 to the dining room for an activity. CNA B said Resident #26 had not been given a shower yet, but she shaved her face (no hair was observed at this time on her face). CNA B said Resident #26 is very compliant and never had any problems with shaving her face then contradict herself saying Resident #26's face was not shaved on 02/05/2023 because she refused to be shaved. Observation on 02/05/23 at 3:30 PM revealed Resident #26's toothbrush was dry; food was visible in-between her teeth, and heavy hair was noted on her face. Observation on 02/06/2023 10:30 AM revealed Resident #26's toothbrush was dry, food was visible in-between her teeth, and heavy hair was noted on her face (facial hair was approximately one sixteenth of an inch long with a mixture of gray and black hair). During an interview on 02/07/2023 at 9:30 AM the Administrator, DON, ADON, and Corporate Nurse stated their expectation with ADLs was they should be completed by nursing staff during their shift. The Administrator and Corporate Nurse were asked for policy and procedure regarding ADLs on 02/06/2023 at 2:00 PM and on 02/07/2023 at 1:30 PM and 2:00 PM without success. 676148 Page 5 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 provide supervision to prevent a potential hazard for 1 (Resident #5) of 25 residents eating in the facility's only dining room from spreading disease. During lunch service on 02/07/2023 at12:35 PM Resident #5 was observed eating left-over food meant to be discarded. The facility's failure to supervise wandering Resident #5 from eating discarded food could potentially place residents at risk for spreading disease. Findings included: Record review of Resident #5's undated face sheet, revealed she was a [AGE] year-old female admitted to the facility on [DATE], with the diagnoses: Alzheimer's disease, major depression, persistent mood disorder, and insomnia (difficulty sleeping). Record review of Resident #5's quarterly MDS dated [DATE] revealed she had a BIMS of 00 indicating she was severely cognitively impaired and unable to answer questions related to BIMS score. The MDS reflected under Section C - Cognitive skills for daily decisions the resident scored a 3 indicating severely impaired cognition - never/rarely made decisions. Section E reflected (Behavior) Wandering - presence & frequency (code 3) revealed behavior of this type occurred daily. Review of Resident #5's Care Plan dated 10/17/2022 revealed the following: Goal: Resident #5 will be able to communicate basic needs daily. Interventions: Provide the resident with necessary cues Care plan dated 03/08/2022 revealed the following: Focus: Resident #5 has unplanned/unexpected weight loss related to food intake. Resident #5 will maintain her nutritional status within ideal body weight. Goal: Resident #5 will maintain her nutritional status within ideal body weight range without complications. Give resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis Intervention: Give resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. Review of Resident #5's physician's orders dated from admission [DATE] to 11/21/2022 did not address supplemental nutrition interventions. Review of Resident #5's weight dated from 05/03/2022 to 11/02/2022 revealed a 6-pound increase. On admission [DATE] her weight was 128.8 pounds and on 05/03/2022 there was a 13.6-pound weight loss. 676148 Page 6 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 02/05/2023 at 12:00 PM lunch service revealed approximately 25 residents were sitting in the dining room and 3 residents were wandering in the dining room. Resident #5 was assisted to her table and later noted wandering near the leftover food cart after eating her lunch at approximately 12:30 PM. During an observation on 02/05/2023 at 12:35 PM revealed after lunch service Resident #5 was standing over the food trays from residents who did not finish their meal. The leftover food were on plates and placed on a rolling cart in the dining room beside a wall which was accessible to all wandering residents in the dining room. Resident #5 was observed eating leftover chicken drumstick and leftover (what appeared) to be pecan pie also on the leftover food cart. Staff working in the dining room were unaware Resident #5 was eating leftover food until they were made aware by the surveyor this was happening. Resident #5 was redirected away from the discarded food at this time. Staff then placed the leftover food into the garbage dispenser located beside the roll away cart. Review of the facility menu dated 02/06/2023 revealed on 02/05/2023 the lunch meal included fried chicken drumsticks and pecan pie. During an observation on 02/06/2023 at 12:45 PM revealed staff were putting leftover unfinished food in a garbage dispenser (beside the roll away cart) and the emptied plates were placed on the roll away cart and taken to the kitchen to be washed in the dishwasher. During an interview on 02/06/2023 at 12:45 PM the DON identified Resident #5 as the wandering resident who ate from the leftovers on the roll away cart used for discarded food. The DON said sometimes staff forget to empty the trays with leftover food into the garbage dispenser. She said they should have emptied the leftovers into the garbage dispenser yesterday (02/05/2023). She said her expectations were that staff should empty food into the garbage dispenser to keep wandering residents from eating leftovers. DON said the facility had 9 residents who were COVID-19 positive and could spread the disease to asymptomatic (without symptoms) residents who ate in the dining room meant to be discarded, failure to discard the food could potential spread COVID-19. During an interview on 02/07/2023 at 8:50 AM the Dietary Aide said she had seen Resident #5 eat leftover food from the roll away cart on different occasions. She said nursing staff knew they were supposed to empty the leftover food into the garbage dispenser. She said nursing staff sometimes got rushed and forgot. She said she had seen Resident #5 and another resident eat leftover food that should have been discarded but did not know the other residents' names. During an interview on 02/07/2023 at 9:30 AM with the Administrator, DON, ADON and Corporate Nurse, they said staff needed to monitor wandering residents and leftover food should be discarded immediately to prevent the potential spread of disease. The Administrator and Corporate Nurse were asked for policy and procedure regarding the dining room food disposal process on 02/06/2023 at 2:00 PM and on 02/07/2023 at 1:30 PM and 2:00 PM without success. 676148 Page 7 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag: F-732/N-4144 Residents Affected - Many S/S= C Surveyor Name(s): [NAME] RN Immediate Supervisor: [NAME] Based on observation and interview the facility failed to ensure that the daily nurse staffing was posted as required for 3 of 3 days (2/5/23, 2/6/23, and 2/7/23). The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 02/05/23 at 10:30 a.m., revealed the daily staffing pattern was posted on the wall by the front door in a clear acrylic holder however the information was incorrect for 3 of 3 days (02/05/23, 02/06/23, 02/07/23). Observation on 02/05/23 at 1:00 p.m., revealed the daily staffing pattern was posted on the wall by the front door in a clear acrylic holder and dated 01/26/23, which did not reflect the current date which was 02/05/23, the resident census was posted as 40, however a review of the facilities 802 dated 02/05/23 reflected a current resident census of 42, and the daily staffing pattern dated 02/05/23 the actual hours scheduled by licensed and unlicensed staff, not the actual hours worked by licensed and unlicensed staff. Observation on 02/06/23 at 9:30 a.m. and 2:30 p.m. revealed the daily staffing pattern was posted on the wall by the front door in a clear acrylic holder and dated 02/6/23 and did not reflect the correct resident census or actual hours worked by licensed and unlicensed staff. the resident census was posted as 41, however a review of the facilities 802 dated 02/06/23 reflected a current resident census of 42, and the daily staffing pattern dated 02/05/23 the actual hours scheduled by licensed and unlicensed staff, not the actual hours worked by licensed and unlicensed staff. Observation on 02/07/23 at 11:30 a.m. and 2:00 p.m. revealed the daily staffing pattern was posted on the wall by the front door and dated 02/7/23 did not reflect the correct resident census or actual hours worked by licensed and unlicensed staff. the resident census was posted as 41, however a review of the facilities 802 dated 02/07/23 reflected a current resident census of 38, and the daily staffing pattern dated 02/07/23 the actual hours scheduled by licensed and unlicensed staff, not the actual hours worked by licensed and unlicensed staff. During an interview with the Administrator, DON, ADON, and Corporate Nurse on 2/7/23 at 10:10 a.m., all where in agreement that the required daily staffing posting was supposed to be posted on a daily basis by the DON and reflect the correct date, correct resident census or actual hours worked by licensed and unlicensed staff. The facility did not have a policy on required staffing posting. 676148 Page 8 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 one of one kitchen reviewed. Residents Affected - Many 1. The refrigerator did not have a manual thermometer located inside where food was stored. 2. Raw food was improperly stored in the freezer. 3. Employees failed to wash their hands using the handwashing sink between tasks and exiting or the entering kitchen during meal preparation. These failures by the facility placed residents at risk of acquiring foodborne illnesses and a decline in health status. Findings include: Observation on 02/05/2023 at 9:05 AM, during initial tour of kitchen revealed there was a large box fan sitting in the handwashing sink that was turned on and running. While preparing lunch [NAME] 1 used the hand soap above the handwashing sink and then went to a food preparation sink to wash her hands. Observation on 02/05/2023 at 12:42 PM revealed the DSM was observed pulling her N95 face mask down and touching her face before pulling the mask back up. She did not wash her hands before resuming her work in the kitchen preparing for the next meal and handling several drinking glasses that were clean. Observation on 02/05/2023 at 12:44 PM revealed [NAME] 1 was seen leaving the kitchen and returning at 12:48 PM. Upon entry into the kitchen [NAME] 1 failed to wash her hands before resuming her work preparing the evening meal. Observation on 02/06/2023 at 10:25 AM revealed the kitchen refrigerator sitting in the dining room along a back wall. The refrigerator did not have an internal, manual temperature thermometer. The DSM promptly went to her office and got a new one to put into refrigerator. Observation on 02/06/2023 at 10:35 AM revealed packaged uncooked bacon in the freezer sitting on top of a box of cooked sausage. Observed raw, frozen chicken stored on a shelf with uncooked beef below it. There were no drip trays separating the raw meats. In an interview on 02/06/2023 at 10:20 AM, [NAME] 1 said the box fan was in the handwashing sink the day before because the kitchen was so hot. She said they just used the soap from the hand sink and 676148 Page 9 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many went to the other two-compartment prep sink to wash their hands. [NAME] 1 indicated she forgot to wash her hands when she went back into the kitchen after going to another part of the facility. [NAME] 1 said she knew they were not supposed to do that and should have washed her hands. In an interview on 02/06/2023 at 10:45 AM, the DSM said she knew that raw bacon should not be stored on top of pre-cooked food and that chicken should not be stored above other raw meats. She said she knew everyone was supposed to wash their hands while working in the kitchen. In an interview on 02/06/2023 at 3:40 PM, the Administrator said she was aware that frozen food was improperly stored from the DSM telling her about it and, she also said it was her understanding that chicken should not go above beef even though she was not aware it was happening then at the facility. Record review of a facility policy titled Storage Refrigerators from the Dietary Services Policy & Procedures Manual 2012, no date, IC 00-10.0 revealed in part the following: All Storage Refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage. Procedures: 1. Storage refrigerators shall be well lighted, ventilated, temperature controlled, and must have an internal thermometer. 2. Storage refrigerators shall have thermometers frequently monitored throughout the day and recorded in the am and pm shifts. Temps are recorded on the Refrigerator/Freezer Log. The refrigerator should be 41 degrees F or less, and the freezer should be maintained at less than 0 degrees F. Record review of a facility policy titled Infection Control from the Dietary Services Policy & Procedure Manual 2012, no date, IC 00-1.0 showed the following: Procedures: 3. Careful hand washing by personnel will be done in the following situations: a. Prior to entering the work area and reporting to the work station. b. Between handling of dirty dishes, boxes, or equipment and handling clean food or utensils. 676148 Page 10 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0812 c. Level of Harm - Minimal harm or potential for actual harm After going to the restroom, after breaks or smoking. d. Residents Affected - Many Between handling of cooked and uncooked foods. e. After each instance of coughing, sneezing, touching face and or hair. f. After visiting resident room, prior to returning to food production area. A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. Record Review of the Food and Drug Administration's Food Guide 2017, Annex 3, Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food-Protection Separation, Packaging, and Segregation, page 421 paragraph two, reflected, With regard to the storage of different types of raw animal foods as specified under subparagraph 3-302.11(A)(2), it is the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage, preparation, holding and display will prevent cross-contamination from one to the other. The required separation is based on a succession of cooking temperatures as specified under § 3-401.11 which are based on thermal destruction data and anticipated microbial load. For example, to prevent cross-contamination, fish and pork, which are required to be cooked to an internal temperature of 145°F for 15 seconds, shall be stored above or away from raw poultry, which is required to be cooked to an internal temperature of 165°F (<1 second instantaneous) due to its considerably higher anticipated microbial load. In addition, raw animal foods having the same cooking temperature, such as pork and fish, shall be separated from one another during storage and preparation by maintaining adequate spacing or by placing the food in separate containers because of the potential for allergen cross-contamination or economic adulteration via inadvertent species substitution. 676148 Page 11 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to dispose of garbage and refuse properly for one of two dumpsters. Residents Affected - Many One dumpster was uncovered and overfilled and there was trash on the ground near the uncovered dumpster. This failure placed residents at risk of acquiring diseases from invasive species such as rodents and flying insects attracted to open containers of trash. Findings include: Observation on 02/06/2023 at 10:30 AM, revealed two dumpsters in the back of the building. One was a traditional large box dumpster commonly found at local businesses was almost empty. The lid and doors were shut. Next to the box dumpster was a large open top roll-off dumpster The open top dumpster had furniture, and a large number of plastic bags in it that reached well above the top of the sides of the container. The contents of the clear trash bags were things found in resident rooms, such as paper trash, adult briefs, wet wipes and other garbage associated with resident use. There was no type of cover on the container and all the trash within was exposed to the elements and any possible intrusion by pests, or rodents. There was a plastic bag near the edge of the container that contained what looked like old, uncooked dinner rolls. Observation on 02/06/2023 at 10:35 AM, revealed loose trash, paper and other debris on the ground next to the building adjacent to the open dumpster. In an interview on 02/06/2023 at 10:45 AM, the DSM said the open top dumpster was brought in to use while the facility was getting rid of old furniture and office equipment from the previous owners of the facility. The DSM said the CNAs were using the dumpster because the other one was often too full to use. In an interview on 02/06/2023 at 11:38 AM, the Administrator said the open top dumpster was brought in to help with all the old office equipment and clutter around the facility. The ADM said the dumpster was supposed to be removed the next day. On 02/06/2023 at 12:55 PM there was a request for a facility provided policy regarding waste containers outside the building that was never provided. 676148 Page 12 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

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 infections for1 (Resident# 92) of 2 residents observed for incontinent care. Residents Affected - Few The facility failed to ensure Resident #92 was provided incontinent care by staff who demonstrated correct infection control procedures. These failures could place residents at risk for acquiring and/or spreading infectious diseases. Findings included: Record review of Resident #92's Face Sheet, dated 2/7/23, indicated a [AGE] year-old male. He was admitted to the facility initially on 2/3/23 with diagnoses that included Alzheimer's Disease, Anxiety Disorder, Insomnia, and Essential Hypertension. Record review of Resident #92's admission MDS dated [DATE] indicated a BIMS of 3 or severe cognitive impairment. Resident #92 required extensive assist of one to two persons for ADLs and was always incontinent of bowel and bladder. Record review of Resident #92's Care Plan with a revision date of 2/6/23 indicated the following: Focus: Resident #92 had bladder incontinence related to Alzheimer's, Dementia, Inability to Communicate Needs, and ADL Deficit. Interventions: Incontinent: check Resident #92 every 2 hours and as required for incontinence. Wash, rinse, and dry perineum (the area between the anus and the scrotum or vulva). During an observation on 2/6/23 at 3:05 p.m. revealed CNA C provided incontinent care to Resident #92. The CNA washed her hands and donned gloves prior to starting care. CNA C then assisted Resident #92 in removing his soiled pants and brief then began incontinent care without removing her gloves and washing her hands that had touched the visibly soiled pants and shoes. CNA C then changed her gloves with gloves she had in her side pocket without sanitizing or washing her hands. She then turned the resident on his side and began wiping the perianal area (area around the anus) of Resident #92. CNA C wiped the resident 6 times with a different wipe each time. CNA C then removed her gloves and grabbed gloves that were stuffed in her side pocket. She donned the gloves she obtained without washing or sanitizing her hands. CNA C then obtained a clean brief and touched the inside of the brief where the brief would be in contact with the resident's perineum. She put the brief on the resident, fastened the brief and assisted with replacing the resident's pants. CNA C removed her gloves, discarded the trash, and washed her hands prior to exiting room with the trash bag from the incontinent procedure. During an interview with CNA C on 2/6/23 at 3:15 p.m., she said she did not wash or sanitize her 676148 Page 13 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hands in between changing gloves while performing incontinent care for Resident #92. She said that was how she usually performed incontinent care. She said gloves should be changed if they became soiled to prevent cross contamination. She said she was not aware that washing hands between gloves changes was required. CNA C stated she had received Infection Control Training in the past. During an interview with the Administrator, DON, ADON, and Corporate Nurse on 2/7/23 at 10:10 a.m., they stated their expectations were that CNAs wash/sanitize their hands per policy when providing resident care. The Administrator said she would have to review their policy and make changes if necessary. The Administrator, DON, ADON, and Corporate Nurse all stated, the staff had been trained on Infection Control. Record review of the facility's Perineal Care policy 04/25/222, indicated the following: Policy Statement: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Definitions Fecal incontinence: the unintentional loss of solid or liquid stool. Urinary Incontinence: the involuntary loss or leakage of urine. Policy Content Equipment and supplies Procedure Content Prepare 10) Perform hand hygiene 11) Don gloves and all other PPE per standard precautions i. Choose your PPE by considering the type of exposure, the durability and appropriateness for the task Front 16) Wipe across the pubis (lower posterior hip bone area) area 676148 Page 14 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 17) Level of Harm - Minimal harm or potential for actual harm Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! Residents Affected - Few Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. Male resident: If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Pull back the foreskin on uncircumcised mates. Hold penis by the shaft. Wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh. Reposition foreskin of uncircumcised males. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. 18) If visibly moist, pat the areas dry with a clean, dry towel or washcloth 19) Note skin changes and apply moisture barrier cream as directed Back 20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area 22) If visibly moist, pat the areas dry with a clean, dry towel or washcloth 23) Note skin changes and apply moisture barrier cream as directed 24) Doff gloves and PPE 25) 676148 Page 15 of 16 676148 02/07/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 Perform hand hygiene Level of Harm - Minimal harm or potential for actual harm Conclude 26) Residents Affected - Few Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 27) Clean and store reusable items 28) If visibly soiled or contaminated during the procedure, disinfect, or discard the barrier towel on the table 29) Return resident items on the table 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene 676148 Page 16 of 16