Health inspection·January 19, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 5 residents (Resident #199) and 1 of 2 Nurse Medication Carts reviewed for medications in that: -The facility failed to ensure the Nurse Medication Cart Second Floor B Side was locked when unattended. -The facility failed to ensure Resident #199 did not have medication in her room. These failures could affect all residents and place them at risk for medication diversion, being administered the wrong medication, injury, and hospitalization. Findings include: Observation on 01/17/2023 at 12:37 PM, revealed the Nurse Medication Cart Second Floor B Side was parked in the hall across from the nurse's station unlocked no staff, visitors, or residents were in the area. Observation on 01/17/2023 at 12:40 PM, revealed LVN A returned to the Nurse Medication Cart Second Floor B Side. LVN A stated the reason she left the medication cart was because she rushed to the dining room to make sure the resident she gave insulin too received his lunch immediately. LVN A stated when leaving the medication cart it was the nurse working on the cart's responsibility to push the lock in and make sure it was locked before leaving it. LVN A stated she did not lock the medication cart prior to leaving due to being rushed. LVN A stated the risk of leaving the medication cart unlocked was that a resident would be able to get into the medication cart and get medicines from it. The medication cart was to be locked when it was unattended. Inventory of the Nurse Medication Cart Second Floor B Side at 1/17/2023 at 12:40PM time accompanied by LVN A revealed: Drawer 1: insulins, eye lid scrub pads, eye drops, Drawer 2: locked empty narcotic box, resident individual medications, MiraLAX (laxative for constipation), nasal allergy sprays, Page 1 of 9 676152 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0761 Drawer #3: Betadine (skin antiseptic), nystatin cream (antifungal), lidocaine patches (pain patches), Level of Harm - Minimal harm or potential for actual harm Drawer #4: Gloves, medication administration supplies. Residents Affected - Some In an interview on 01/18/2023 at 2:45 PM, the DON stated her expectations were the medication carts were not to be left unlocked when unattended. The DON stated medication carts were to be locked by the staff member working on the cart. The DON stated the staff working on the cart was responsible for locking the cart. The risk of an unlocked medication cart was that anyone could take medications out of the medication cart. The plan was to inservice the staff that the medications carts were to be locked when leaving it. The staff have been inserviced in the past regarding locking medication carts. In an interview with the Administrator, he stated the staff member working on the medication cart was the one responsible for making sure the cart was locked when out of their sight. The Administrator stated it was important to lock medication carts to prevent the resident from access to the medications in the medication cart. The administrator stated the unlocked medication cart could affect the resident in two ways one was a medication may be taken out of the cart and not available to administer when needed or a resident may take a medication they should not have. The Administrator stated the plan to prevent this again the DON has begun inservices for all staff working on the medication cart. Resident #199 Record review of the admission sheet (undated) for Resident #199 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), pressure ulcer of left buttock, stage 3 (an injury that affects areas of the skin and underlying tissue) and hypertension (A condition in which the force of the blood against the artery walls is too high). Record review of Resident #199's Comprehensive MDS assessment, dated 01/14/2023, revealed a BIMS score was blank her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Record review of Resident #199's care plan, dated 01/18/2023 revealed the following care plan: Problem: cognitive loss/ dementia. Have mild cognitive impairment as evidenced by need for assistance with daily decisions, forgetfulness at times. Goal: I will utilize my existing cognitive abilities. I will have choice and control in decision making. Approach: Staff will provide reminders as needed. Staff will encourage reminiscence to stimulate memory. Staff will help me explore and focus on my strengths and talents. Staff will honor my right to have choice and control. Resident #199 was not care planned for having meds at bedside. During an observation and interview on 1/7/23 at 10:03 a.m., of Resident #199, in her room, 676152 Page 2 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed a bottle of Women's multivitamin with iron, bacitracin [NAME] ointment and pill reminder box with pills in it sitting on top of the bedside table. Resident #199 said her friend brought OTC/meds sitting at bedside 3 days ago. Resident #199 was unable to name the pills in the pill reminder box. Record review of Resident #199's physician's order revealed Resident #199 was not prescribed the above-mentioned medication. There were no orders for self-administration. During an observation and interview on 1/17/23 at 11:39 a.m. with LVN B, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. She said she did not know how the medications got in her room. LVN B said the resident did not have orders for it. LVN B asked Resident #199 you know who brought these meds. Resident #199 said, 3 days ago my friend brought it. LVN B took the medication and told Resident #199, If you need these medications, we have it at the facility, but I need to get an order for it. I am going to have to take it with me and give it to my supervisor. She said we needed to verify any allergy or adverse effect of the medication before giving it to the resident. She said the doctor had to approve it first. In an interview on 1/18/23 at 2:40 p.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said Resident #199 was not deemed safe to have medications in her room. She said nurses made rounds and were responsible for checking the rooms for medications. She said Resident #199 told her that her friend brought those meds night before yesterday. She said 11-7am shift nurse should have noticed that. She said risk for leaving OTC at bedside was not safe med administration, might not be right dose, have adverse effect, OTC meds could interact with prescribed meds, overdose and wanders can get hold of meds. Record review of facility's Medication Storage Bedside Medication storage policy (dated 05/16) read in part: .5. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary . Record review of the facility's policy, Medication Administration dated November 2017 read in part Policy: To administer oral medication in an organized, accurate and safe manner . Procedures 4. Unlock medication cart. Cart may remain unlocked only when in direct line of sight and control by the nurse or medication aide who is administering medication . 676152 Page 3 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 01-17-23 at 8:30 am revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the door was open. Interview on 01-17-23 at 8:45 a.m., with the Executive Chef he stated that the dumpster lids always must be closed to prevent infestation with rodents and bugs out of the dumpster and from entering the facility. He stated that he will do an in-service training with the facility staff. Record review of facility policy and procedure on waste disposal dated 01/01/23, indicated: Procedure : 3. The dumpster doors are to be closed after each deposit and are to remain closed when not in use. 5. If any [facility name] employee observes the dumpster doors being left open when not in use, please close them or call Housekeeping at ext. 737/239/289 or cell phone number [PHONE NUMBER].6. Housekeeping Porters and Dining Services utility employees are the normal people that take garbage to the dumpsters. 676152 Page 4 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #50) reviewed for PASARR. -Resident #50 with diagnoses of mental illness did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #50's face sheet, undated revealed Resident #50 was a [AGE] year-old female, admitted to the facility on [DATE], with the following diagnoses: bipolar disease (a brain disorder that causes changes in a person's mood, energy, and ability to function), paranoid personality disorder 9 a mental condition in which a person has a long-term pattern of distrust and suspicion of others) and unspecified mood [affective] disorder (mental disorders that primarily affect a person's emotional state). Review of Resident #50's admission MDS dated [DATE], revealed, in the section pertaining to PASARR, the assessment indicated Resident #50 did not have a serious mental illness. Review of the admission PASARR Level I for Resident #50 dated 03/01/2021 revealed it indicated yes to the question: Is there evidence or an indicator this is an individual that has a Mental Illness? Review of Resident #50's clinical record revealed there was no evidence that Resident #50 had a PASARR Level II Screening. Record review and interview on 01/19/23 at 1:04 p.m., the DON provided a copy of documentation dated 03/08/2021 indicating Resident # 50 was eligible for PASARR Specialized Services. In an interview on 01/19/23 at 12:39 p.m., with the MDS Coordinator. MDS Coordinator said the Director of Nursing (DON) was responsible for completing the PASARR. PASARR I was completed for all residents of the facility. MDS Coordinator said after the results were sent to the state agency immediately upon completion of the PASARR I. Following a positive PASARR I determination the state agency would make contact with the facility to organize an interview of the resident to determine the resident was eligible for additional therapeutic services. MDS coordinator said she did not complete any follow-up related to the PASARR system. MDS Coordinator said the DON would be responsible for any follow-up concerning the PASARR system. In an interview on 01/19/23 at 12:46 p.m., with the DON, she said the facility had reached out to the state agency yesterday 1/18/2023 after Surveyor's questioning of Resident#50's PASARR 11 screening. The DON said she requested information regarding the PASARR II interview and services for Resident #50. DON said the facility had not yet heard back from the state agency as of today (1/19/23). DON said PASARR I indicated a resident was eligible for PASARR II services but there was no communication from the state agency after PASARR I. She said she should have made a phone call to follow-up on 676152 Page 5 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the status of the interview. DON said there was no policy in place to address when a PASARR I with a positive determination was not followed up by the state agency to schedule PASARR II interview. DON said a resident may not receive the services he/she needed if the PASARR II interview was not completed. Review of Facility's Coordination-Pre-admission Screening and Resident Review (PASARR program) policy (not dated) read in part: .2. Coordination includes: a. incorporating the recommendations from the PASARR level ll determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. b. Referring all level ll residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level ll resident review upon a significant change in status assessment . 676152 Page 6 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

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 prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident#53) reviewed for infection control, in that: Residents Affected - Some - The Wound Care Nurse failed to perform hand hygiene when moving from a dirty to clean site, while performing Resident #53's wound care. This failure could place residents at risk for or infections. Findings included: Record review of the admission sheet for Resident #53 revealed he was [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His diagnoses included pressure ulcer of right buttock (an injury that breaks down the skin and underlying tissue), stage 3, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and pressure ulcer of other site, unstageable (an injury that breaks down the skin and underlying tissue). Record review of Resident #53's Comprehensive MDS assessment, dated 11/07/2022, revealed a BIMS score of 99 out of 15. Staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. He was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Further review of Section M0150 revealed Resident #53 was at risk of developing pressure ulcer or injuries. Section M0210. Does this resident have one or more unhealed pressure ulcers/injures? Coded yes. Record review of Resident #53's care plan, initiated 11/18/22 and revised on 01/13/2023, revealed the following: Problem: I have a diagnosis of a pressure ulcer. Location/stage: Right ischial/stage 3; 12/7/22 RE-classified as stage 4. Goal: Ulcer will heal without complications. Approach: Treatment per MD orders. If wound care treatment is not responding or declining to current treatment notify MD/NP every week and prn. Record review of Resident #53's physician order, dated 01/11/2023, revealed an order to cleanse wound with normal saline, apply Alginate w/ silver , cover wound with dry absorptive dressing daily. Record review of Resident #53's Wound Care evaluation dated 01/11/2023 read in part: .S/S of Infection: confirmation description & Treatment plan: signs & symptoms present, Topical Antibiotics prescribed. Assessment Notes: fractured bone within wound bed indicates clinical osteomyelitis but [family member] does not want aggressive IV antibiotics . 676152 Page 7 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 01/19/2023 at 10:02 a.m., revealed the WCN provided wound care for Resident #53. The WCN was assisted by the Unit Manager. Without performing hand hygiene and donning clean gloves the WCN gathered the supplies from the treatment cart (contaminated them by opening several packages of 4 x 4 gauze, dry dressing, package of silver alginate, 2 prefilled normal saline syringes, 2 swab sticks and placed two dry 4 x 4 gauze in 2 separate medication cups) placed on the bedside table in the hallway, then brought them in to Resident #53's room. The WCN assisted Resident#53 turn onto his left side. Unfastened the brief and tucked a clear trash bag under the resident. Observation revealed there was a dressing on the resident's right ischial area. The dressing contained a moderate amount of bloody drainage. There was no date visible on the dressing. Continued observation revealed WCN removed the dressing and discarded it into the clear trash bag tucked under the resident. The resident exhibited an open area on the right ischial area, of approximately 4cm, with superficial depth. The WCN did not clean the right ischial wound from the inside to out. WCN nurse used the contaminated swab to insert the silver alginate to pack the wound. The WCN changed gloves 2 times during the wound care and placed her dirty gloves, dirty 4 x 4 gauzes on the resident bed pad. Contaminating the resident's bed pad. The WCN picked up soiled gauze, dirty gloves and placed it back in the clear trash bag tucked under the resident. The WCN then placed the trash bag on the bedside table. The WCN then fasten the same dirty brief, touched the bed linens, fixed resident's shirt, repositioned and covered the resident. The WCN did not clean the resident's bedside table. Placed Resident's water cup from the side table on to the bedside table. The WCN exited the room without sanitizing her hands with the clear trash bag. In an interview on 01/19/2023 at 10:15a.m., with the WCN , she said she was not a certified wound care nurse. She said she started working at this facility a month ago. She said she had received 3 days of training on the floor with another wound care nurse. She said she did not recall having to do wound care competency checks with the DON. She said the facility provided in-servicing on infection control upon orientation. She said she could not recall the exact date. She said she performed hand hygiene when Surveyors asked to observed wound care. She said, I had to go look for help. Grabbed the Unit Manager to assist and prior to that had to help another resident that was high fall risk. She said she did not recall performing hand hygiene prior to setting up supplies on the hallway as she was nervous. She said, I did not wash my hands prior to leaving the room because the trash bag was dirty. I had to carry the trash bag out of the room. I washed my hands after I threw the trash bag away. When Surveyors shared the wound care observation from earlier, the WCN . The Wound Care Nurse said, I disagree. Have a good day and turned her back. In an interview on 1/19/23 at 10:26 a.m., with the DON, she said she expected staff to follow standard infection control techniques; to perform handwashing before the treatment, between gloves change and after, before leaving the room as it placed risk for infections. She said staff were provided training on infection control and hand hygiene often. She said the WCN was observed by the downstairs WCN and person that provided wound care supplies. She said she had not spot-checked the WCN. She said the potential risk to the resident, due to this failure, was cross contamination. At this time, WCN competency check off was requested. In a telephone interview with the Wound Care Doctor on 1/19/23 at 11:36 a.m., he said, Resident #53's wound is bad, super bad, has foul odor and bone infection. He said he was using Silver Alginate as topical antibiotic. He said silver fought infection and Alginate absorbed heavy drainage due to infection. He said Resident #53 needed IV antibiotics to treat osteomyelitis but the family member refused aggressive treatment. He said, all we can do now is to provide proper wound care as the bone infection will not treat itself without 6 weeks of IV antibiotics). 676152 Page 8 of 9 676152 01/19/2023 Seven Acres Jewish Senior Care Services 6200 N Braeswood Blvd Houston, TX 77074

F 0880 WCN competency check off was not provided upon exit. Level of Harm - Minimal harm or potential for actual harm Record review of facility's Infection Control policy (dated 1/2/21) read in part: .Purpose: to establish need for infection control policies in the facility. [facility name] has multiple policies for infection control. Each organism causing an infection may be difficult to resolve if treated in the same fashion . Residents Affected - Some Record review of facility's Handwashing Technique policy dated 11/30/16 read in part: .Policy: All staff will use correct handwashing techniques as follows: A. All staff should wash their hands with soap and water whenever the potential exists for contact with blood, bodily fluids, mucus membranes and/or non-intact skin. Hand sanitizers not to be used if hands are visibly soiled. B. Hand washing should be done at the following times: Prior to wearing gloves and after removing gloves. Before & after changing a dressing. Purpose: To provide correct and effective handwashing technique by staff which will reduce the spread of infections among staff, residents, families and visitors . 676152 Page 9 of 9