Health inspection·March 19, 2025

F 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected resident's status for 3 (Resident #9, Resident #43 and Resident #380) of 6 residents reviewed for accuracy of assessments. Residents Affected - Some The facility failed to ensure that Resident #9's admission MDS dated [DATE] accurately reflected her inability to hear normal conversation and her oral dental need. The facility failed to ensure that Resident #43's quarterly MDS dated [DATE] accurately reflected the resident had functional limitation in range of motion of upper and lower extremities. The facility failed to ensure that Resident #380's discharge MDS dated [DATE] accurately reflected the resident's fall that occurred on 2/8/25. These failures could place residents at risk of receiving inadequate care and services based on inaccurate assessments. Findings include: Resident #9 Record Review of Resident #9's face sheet dated 3/19/25, revealed [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified fracture of the T9-T10 vertebra (primary diagnoses) rib fracture left side , heart disease, Essential hypertension, hypothyroidism (a condition that occurs when the thyroid gland doesn't make enough thyroid hormone), pain and muscle weakness. Record review of Resident #9's admission MDS dated [DATE] revealed her BIMS score was coded as 14 out of 15 which indicated she was cognitively intact. On hearing, speech, and vision she was coded as adequate. On oral dental status she was coded as Z which indicated no problem with her oral cavity. Observation and interview on 03/17/25 at 10:50 AM revealed Resident was sitting in her chair between her bed and her roommate. Observation revealed she had her glasses on , and a dental cup was on her nightstand. During the interview, she stated several times that she could not hear and said to speak louder because she was hard of hearing. A writing pad was used during the interview. She said she had dentures, and her lower dentures were in the dental cup on her nightstand. She said she did not wear her dentures because the lower dentures didn't fit and needed adjustment. She said it was hard to eat certain food items if not soft enough. She said she had a cavity on one of her upper teeth . Page 1 of 16 676155 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the MDS Coordinator on 03/18/25 at 2:50PM he said he was not responsible for section L of the MDS. He said section L (oral dental section of the MDS) He said that section of the MDS was done by speech therapy and if a resident needed a dental examination, the Social Worker would add the resident's name to the list . During an interview with the Speech therapist on 03/18/25 at 3:40PM, she said she assessed residents recommended to her due to swallowing difficulty such as dysphasia , and those who hads strokes. She said she assessed for the ability to swallow. During an interview with the DON on 03/19/25 at 10:40 AM, she said the MDS (PPS) Ccoordinator was responsible for ensuring that all MDS assessments accurately reflected the resident's condition. Resident #43 Record Review of Resident #43's face sheet dated 3/19/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Stiffness of Right Hand, Stiffness of Left Hand, Cerebral Infarction (Stroke) and Hemiplegia (one sided weakness or paralysis) and Hemiparesis (weakness in one leg, arm, or side of the face) affecting Right Dominant Side. Record review of Resident's #43's quarterly MDS dated [DATE] revealed that BIMS could not be conducted. It was also revealed in section GG0115 completed by the MDS Coordinator/PPS Coordinator the resident did not have any limitations captured for the upper or lower extremities. Record review of Resident #43's doctor's progress note dated 10/17/2024 revealed that Resident #43 had a CVA (Stroke) with right sided deficits and severe cognitive deficits. Record review of Resident #43's Physical Therapy Evaluation & Plan of Treatment dated 5/16/24 revealed Resident #43 had bilateral (both) lower extremity contractures (condition that causes limited movement of a joint). Record review of Resident #43's Physical Therapy Treatment Encounter Note dated 6/20/24 revealed the resident had bilateral lower extremity contractures (condition that causes limited movement of a joint). Record review of Resident #43's care plan revealed Resident #43 had a history of CVA (Stroke) and right hemiparesis (weakness in one leg, arm, or side of the face), aphasia (inability to comprehend or communicate) and dysphagia (difficulty swallowing) with a start date of 1/1/24. Observation on 3/18/25 at 1:15 p.m., revealed Resident #43's legs were bent and drawn up towards his trunk. During an interview on 3/19/25 at 9:35 a.m., LVN L said that Resident #43 had weakness in his right arm and leg, and they were contracted. During an interview on 3/19/25 at 9:48 a.m., ADON A said that Resident #43 was contracted. ADON A said that Resident #43 had diagnosis of hemiplegia/hemiparesis of the right dominant side and stiffness of the left hand. 676155 Page 2 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interview on 3/19/25 at 10:10 a.m., the MDS Coordinator/PPS Coordinator said that Resident #43 had weakness but was not contracted that limited his range of motion to be able to do things like dressing. Resident #380 Record Review of Resident #380's face sheet dated 3/19/25, revealed resident is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (Chronic Lung Condition causing Restricted Airflow), Unspecified Atrial Fibrillation (Irregular Heartbeat) and Type 2 Diabetes Mellitus. Record review of Resident #380's quarterly MDS dated [DATE] revealed a BIMS score of 9 that suggested moderate cognitive impairment. Record review of Resident #380's discharge MDS dated [DATE] revealed in section J1800 the resident had not had any falls since admission/entry or reentry or to the prior assessment. Record review revealed Resident #380 had MDS assessments completed on 2/7/25 and 3/6/25. Record review of Resident #380's Search Progress Notes for 2/8/25 revealed that LVN I documented on 2/8/25 at 07:30 a.m. Resident #380 was found on top of his fall mat on the floor lying on his left side. During an interview on 3/19/25 at 9:48 a.m., ADON A said that LVN I had documented regarding Resident #380's fall on 2/8/25 that he was having agitation and restlessness and had thrown items on the floor. ADON A said that per LVN I's documentation he was found on top of the fall mat. ADON A said she worked on 2/8/25 but was not working at the time of Resident #380's fall. During interview on 3/19/25 at 10:03 a.m., the MDS Coordinator/PPS Coordinator said that if the MDS was not correctly completed then the facility may not be adequately able to provide for the resident. During interview on 3/19/25 at 10:10 a.m., the MDS Coordinator/PPS Coordinator said he would have to review Resident #380's chart and if he missed a fall then he would correct the MDS. During interview on 3/19/25 at 10:15 a.m., the MDS Coordinator/PPS Coordinator said he made a mistake regarding the MDS for Resident #380 and had missed the fall. The PPS Coordinator said he updated the discharge MDS dated [DATE] to reflect the fall. Record review of Resident 380's corrected discharge MDS dated [DATE] completed by MDS Coordinator/PPS Coordinator revealed in section J1800 that resident had fallen since admission/entry or reentry or the prior assessment. The Surveyor attempted to contact LVN I on 3/19/25 at 2:05 p.m. but was unable to reach LVN I or leave a voicemail. During interview on 3/19/25 at 2:52 p.m., the DON said the PPS Coordinator is who completed the MDS. The DON said that when the MDS was ready to be transferred she would check to see if the MDS was completed. The DON said that the MDS Coordinator checked the MDS for accuracy. 676155 Page 3 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interview on 3/19/25 at 2:56 p.m., the Administrator said that PPS Coordinator was the MDS Coordinator who managed the MDS' and agreed he would be the one to check for accuracy. Record review of facility's Nursing Policies and Procedures with subject MDS - Primary Assessment with email revision on 9/28/2023 revealed The facility will complete its state-specific version of the Minimum Data Set (MDS) based on the Primary Reason for Assessment within the required timeframes according to applicable low and regulations. 676155 Page 4 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 2 of 3 residents (CR #127 & CR #128) reviewed for discharge summary. The facility failed to complete a discharge summary for CR #127. The facility failed to complete a discharge summary for CR #128. These failures could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: CR #127 Record review of the face sheet for CR #127 revealed a 77- year- old male who admitted to the facility on [DATE] with diagnoses that included, malignant neoplasm of brain (brain cancer), dementia (a condition in which a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with activities of daily life), repeated falls, pain, and seizures. Record review of CR #127's EMR on [DATE] at 11:40 am revealed that CR #127 died at the facility on [DATE] and had no discharge summary. CR #128 Record review of the face sheet for CR #128 revealed [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included End -stage renal failure , hypertensive chronic kidney diseases (commonly known as high blood pressure, heart failure, anemia, (Low red blood count), hypothyroidism (a condition where (the thyroid gland does not produce enough thyroid hormone), and dysphasia (swallowing difficulty) and pain. Record review of CR #128's clinical records revealed he was admitted to the facility on [DATE] and was discharged from the facility on [DATE]. Records review of CR #128 revealed no evidence of discharge summary. Record review of CR #128's Discharge MDS dated [DATE] revealed CR #128 was discharge from the facility returned not anticipated. Interview on [DATE] at 11:56 am with PPS Coordinator (MDS) said there was not a discharge summary for CR #127 in his EMR. The PPS Coordinator said the SW was responsible for completing the discharge summary on all residents. Interview on [DATE] at 12:33pm with the SW who said they did not find a discharge summary for CR #127 in the EMR. The SW said that they did not complete a discharge summary for CR #127 because they 676155 Page 5 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not know they were responsible for completing the discharge summary if a resident passed away. The SW said they thought the charge nurses were responsible for completing the discharge summary for any resident who had an unplanned discharge. The SW said they were only responsible for completing the discharge summary for residents with planned discharges . Interview with the DON on [DATE] at 1:00pm who saidrevealed per the facility policy and procedure, the SW was responsible for completing the discharge summary on all residents' which included both planned and unplanned discharges. Interview with the Administrator on [DATE] at 2:41 pm who saidrevealed they were the direct supervisor of the SW but that the Regional Consultant trained the SW on their job duties which included the completion of forms. In an interview with the facility SW on [DATE] at 3:00PM, sheShe said CR #128 requested to be sent to the hospital and CR #128 was on a special program. She said she did not do the discharge summary because the program that was responsible for CR #128 discharged CR #128 from the program. Attempted telephone interview with the Regional Consultant on [DATE] at 3:04pm and again on [DATE] at 11:48am but was unable to reach prior to facility exit. Follow up interview with SW who said they were trained by the Regional Consultant onand the facility's discharge summary process, but the training only included planned resident discharges. and planned discharges. The SW said they were never trained on completing the discharge summary for resident's who died, because usually when a resident passeds away, the charge nurse completeds the documentation and then discharged s the resident from the electronic medical record system. The SW said they did not know how to complete a discharge summary after a resident was discharged from the computer system, without reactivating the resident in the computer system. The SW said they never asked any questions regarding the discharge summaries for residents with unplanned discharges because it was never an issue until surveyor's began asking questions about the unplanned discharges for residents without discharge summaries . Record review of the facility's policy titled, Social Services Policies and Procedures .Subject: Discharge Summary, dated Complete Revision: [DATE], revealedread in part .A discharge summary is also completed when a resident is fully discharged from the facility (i.e., to another nursing facility, to the community or death).2. The Discharge Summary is completed when the patient or resident is permanently discharged for any reason and return to the facility is not anticipated.3. Each discipline is responsible to complete a section of the Discharge Summary-the Social Worker will initiate the DC Summary for all discharges. 676155 Page 6 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident who displayed or diagnosis with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1(Resident #51) of 5 residents. The facility failed to follow up to ensure Resident #51 received a psychiatric consultation after an order was written on 09/19/2024 from the physician. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings Included: Record review of Resident #51's admission face sheet dated 05/08/2024 indicated an [AGE] year-old female. Resident #51 was admitted with a diagnose of the following: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder. Record review of Resident #51's physician orders dated 9/19/24 read in part consult Deer Oaks for psychological and psychiatric services, med management, may provide psychiatric services. DX: Depression, unspecified. Record review of Resident #51's admission assessment dated [DATE] reflected Resident #51 having a BIMS score of 11 which indicated she had moderate cognitive impairment. Resident #51's mood interview in Section D of the MDS assessment noted Resident #51's total severity score was 11 which could indicate moderate anxiety, depression, or conditions which required further assessments. Record review of Resident's #51's care plan revealed in part: Problem Start Date: 05/14/2024. Category: Behavioral Symptoms resident is having mood and behavior needs as evidence by periods of refusing ADL care, Therapy services, and medications including eye drops. Long Term Goal Target Date: 06/18/2025. Resident will have a reduction in unwanted mood or behaviors, for an increased quality of life by end of next 90-day review. Further review revealed, on 5/24/24 Resident #51's care plan was updated with interventions in place for promptly arrange for psychiatric services for Resident #51 after a displayed increased signs of anxiety and aggressive behaviors dated on 5/14/24. Record review of Resident #51 physician progress notes dated from 2/01/24 to 03/18/2025 revealed no documentation of any referral to psychiatric services. There was no documentation of any physician or nurse practitioner notification for psychiatric related services. 676155 Page 7 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing on 3/18/25 at 1:00PM revealed She cannot explain why the order was not carried out or followed up on and she believed Resident's #51's responsible party declined services. Interview with the MDS nurse on 3/18/25 at 1:45PM revealed awareness of the care plan addressing Resident #51's goals and interventions was to be seen by psychological consult but did not know why she was not seen or followed up on. Interview with the facility Social Worker on 3/18/25 at 2:30PM revealed awareness of the order written for Resident #51. The facility had 2 social workers and she only did short term residents, and the other Social Worker did long term care. The Social Worker stated she was aware of the facility policy for psychological referrals but could not answer as to why Resident #51 was not seen. The facility currently use Deer Oaks company for psychological services, and she did not see Resident's #51's name on the list to be seen. It was believed Resident's #51's responsible party declined services but did not have any documentation for declining services. Social Worker stated due to Resident #51 not getting the psych services she could have a decline in her mental state which could lead to behavior problems. Interview with the long-term social worker on 3/18/25 at 4:15PM, she stated she was not aware of order written for Resident #51. Social worker stated due Resident #51 not receiving psychological services could put Resident #51 at risk for further mental health decline. Interview with Resident's #51's responsible party on 3/19/2025 at 11:35am revealed she was not aware of any orders for Resident#51's needing to see psych services. Record review of the facility's policy on psychological services dated 06/09/2023 revealed ? the following: SOCIAL SERVICES POLICIES AND PROCEDURES SUBJECT: ASSESSMENT AND ANALYSIS OF BEHAVIOR HEALTH NEEDS POLICY: Staff will utilize a knowledge and understanding of mental illness, trauma, substance abuse, disease process and cultural diversity to assess the potential needs of each resident. The staff will incorporate behavior management techniques and cultural knowledge to assist patients/residents in reaching and maintaining their highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and care plan. The assessment includes evaluation of emotional and mental wellbeing, and prevention and 676155 Page 8 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0740 treatment of mental and substance abuse disorders. Level of Harm - Minimal harm or potential for actual harm Social Services or designated staff will facilitate community referrals to meet the needs of the resident related to mood, behavior, mental illness, or cultural identity. Residents Affected - Few PROCEDURES: 1. Evaluate for and identify potential issues related to mental illness, substance abuse, disease process, trauma, and cultural diversity to assist in completing a comprehensive assessment related to mood, behavior, quality of life and personal preferences. Social Services or designee will make referrals for further evaluation, treatment, or support in a timely manner. The assessment will be completed within 7 days of admission to the facility and periodically, as needs are identified. 2. Patients or residents not initially identified as having mental or psychosocial adjustment difficulty who are later diagnosed or identified have medical record documentation to justify why needs were not identified. An example of this documentation would include, Symptoms did not initially manifest, and family was unaware or not forthcoming about past needs. Once needs become evident evaluations/assessments will be completed to ensure needs are documented and a plan of care developed. 676155 Page 9 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 provide or obtain laboratory services ordered by the physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws, to meet the needs for 1 (Resident #380) of 6 residents reviewed for laboratory services. Residents Affected - Few The facility failed to ensure that blood glucose checks that were ordered on 3/17/25 were performed on 3/18/25 and before breakfast on 3/19/25 for Resident #380. The failure could place residents at risk of not receiving timely diagnosis or treatment, and not receiving appropriate monitoring for health and well-being. Findings include: Record Review of Resident #380's face sheet dated 3/19/25, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation (Irregular Heartbeat) and Type 2 Diabetes Mellitus. Record review of Resident #380's quarterly MDS dated [DATE] revealed a BIMS score of 9 that suggested moderate cognitive impairment. Record review of Resident #380's orders revealed an order dated 3/17/2025 for AC bg check Three Times A Day Before Meals 08:00 AM, 12:00 PM, 04:00 PM. Record review of Resident #380's Recent Progress Notes revealed on 3/17/25 at 6:29 p.m. that ADON A documented resident request bg's be assessed due to blood sugars being elevated during hospital stay recently. MD/NP/PA made aware, new order for bg ac. endorsed accordingly. Record review of Resident #380's Search Vitals Results for documented blood sugars revealed no blood sugars were documented before 3/19/2025 at 10:03 a.m. During an interview on 3/17/25 at 9:45 a.m., Resident #380 said that the nurse was going to have to start checking his blood sugars. During an interview on 3/19/25 at 9:48 a.m., ADON A said the resident's blood sugar results should be on a flow sheet in the electronic medical record. ADON A checked Resident #380's electronic medical record but was unable to find any blood sugar results documented. ADON A said she entered the order for Resident #380's blood sugars on 3/17/24 and the blood sugar order went to the wrong flow sheet. ADON A said she updated the electronic medical record now so Resident #380's blood sugars would be on the correct flow sheet. ADON A called RN L and instructed her to check Resident #380's blood sugar now. During an interview on 3/19/25 at 9:57 a.m., ADON A said that RN L notified her via phone that Resident #380's blood sugar was 158. ADON A instructed RN L to notified Resident #380's doctor regarding the blood sugar reading. During an interview on 3/19/25 at 10:32 a.m., the DON said that when an order was entered it would 676155 Page 10 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few go over to the flow sheet which would trigger the nurse to know regarding new orders. The DON said the order should go on the 24-hour report for nurses. During an interview on 3/19/25 at 10:33 a.m., ADON A said that she did not put the order for blood sugar checks for Resident #380 on the 24-hour report for nurses. ADON A said that Resident #380's doctor had instructed to continue to monitor his blood sugars after being notified regarding his blood sugar level this morning. During an interview on 3/19/25 at 12:58 p.m., RN K said that new orders should be documented in the resident's chart and added to the 24-hour report which was a word documented that was updated and printed out nightly. During an interview on 3/19/25 at 1:00 p.m., LVN H said that information regarding new orders were passed along from shift to shift by being documented in the progress notes and the 24 hour nurse report sheet. During an interview on 3/19/25 at 1:07 p.m., MD A said that Resident #380 did not have any adverse effects to not having his blood sugars checked. During an interview on 3/19/25 at 1:07 p.m., ADON A said that Resident #380's blood sugar was 127 and Resident #380's hospice had updated the blood sugar check order to be daily and to notify hospice if the blood sugar was over 250. During an interview on 3/19/25 at 2:18 p.m., RN L said she did not work on 3/17/25 or 3/18/25 so she was not aware that Resident #380 had orders for blood sugar checks. RN L said that when a new order was received then the nurse would enter a progress note and then write on the 24-hour report sheet to endorse to the next nurse. Record review of the facility's Nursing Policies and Procedures revised May 5, 2023, with subject of Blood Glucose Monitoring revealed The facility provides point of care blood glucose monitoring according to standards of practice and infection prevention and control principles. Record review of facility's Nursing Policies and Procedures revised May 5, 2023, with subject Physician Orders revealed that staff should Record order changes in Progress Notes and 24-Hour Report. 676155 Page 11 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

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 observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. Residents Affected - Many -The facility failed to ensure that one of one deep fryer grease was clean. -The facility failed to ensure that the stove in the kitchen was kept clean. -The facility failed to ensure that the rail above the stove was free of grease. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination Kitchen observation and interview with the Dietary Manager on 03/17/25 at 8:45AM, revealed the following: The cooking area revealed the deep fryer had dark looking grease with brown floating substances on top of the grease. In the interview, the Dietary Manager said the grease was supposed to be changed weekly. She was not sure when it was changed last, sometimes last week. Observation of one of two stoves in the kitchen revealed baked on grease (a dark looking substance inside the oven). The Dietary Manager said the stove needed to be cleaned. Observation of the grill above the cooking stove revealed the grease trap rails above the stove had grease dripping along the rail. In an interview the Dietary Manager said the commercial cleaners did clean the grill and the rails . She said she would look to find out when it was last cleaned. She said she was responsible to check to ensure that all areas of the kitchen were clean, but all kitchen employees were responsible for cleaning behind them . She said cooking in an unclean environment may lead to cross contamination and food burn illness. During an interview with the facility's Dietitian on 03/19/25 at 12:05PM he said the Dietary Manager was new and had done a great job cleaning the kitchen. He said the Ddietary Manager was about 3 weeks old at the facility. He said he was at the facility once a week and as needed. He said he provide education and observe meal services from time to time. Record review of fFacility's policy on kitchen sanitation dated 2020 and revised 06/20/2023 revealed in part SUBJECT: SANITATION & FOOD SAFETY IN FOOD AND NUTRITION SERVICES POLICY: The Certified Dietary Manager (COM) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. PROCEDURES: 676155 Page 12 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0812 1. Level of Harm - Minimal harm or potential for actual harm Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness. (Refer to Exhibit 2E, Major Food Borne Illnesses in section J of this manual). Residents Affected - Many 676155 Page 13 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

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 establish and 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 2 (Residents #73 and #119) of 6 residents and 3 of 4 staff (CNA I, CNA J, CNA K) reviewed for infection control. Residents Affected - Some The facility failed to ensure that proper signage was in place for Resident #73 and Resident #119 who were on enhanced barrier precautions. The facility failed to ensure that CNA I, CNA J, and CNA K were knowledgeable and able to appropriately answer questions regarding enhanced barrier precautions. The facility failed to ensure that CNA I was wearing PPE while caring for Resident #73 who was on enhanced barrier precautions. The failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Resident #73 Record Review of Resident 73's face sheet dated 3/19/25, revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (Kidney Failure) and dependence on renal (kidney) dialysis. Record review of Resident #73's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggested cognition was intact. Record review of Resident #73's care plan revealed that EBP during tube feeding/wound care or close contact with wound. PPE required: gloves, gowns, face protection of procedure has risk of splashes or sprays. with approach start date of 12/9/24. Record review of Resident #73's orders revealed active orders dated 3/19/25 related to g-tube (a tube inserted into the stomach for feeding, hydration and medications) site care since of 3/6/2025. Observation on 3/17/25 at 10:22 a.m. of Resident #73's door, room and hallway revealed there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 2:15 p.m. of Resident #73's door and hallway revealed that there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 3:25 p.m. of Resident #73's door and hallway revealed that there was no signage regarding enhanced barrier precautions. During an interview on 3/18/25 at 3:35 p.m., RN M said that Resident #73 should be on enhanced barrier precautions and that supplies of PPE were kept in the resident's top dresser drawer in their 676155 Page 14 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0880 room. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/18/25 at 3:45 p.m., revealed RN M showed the gloves on top of the dresser in Resident #73's room but there were no gowns in the dresser or room that could be found by RN M. Residents Affected - Some During an interview on 3/18/25 at 3:45 p.m., CNA I said that Resident #73 was not on precautions right now but had been before. CNA I denied wearing a gown while bathing or changing Resident #73. Resident #119 Record Review of Resident #119's face sheet dated 3/20/25, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Nontraumatic Intracerebral Hemorrhage (Brain Bleed), Dysphagia (Difficulty Swallowing) and Gastrostomy (Feeding tube inserted in Stomach) Status. Record review of Resident #119's comprehensive admission MDS dated [DATE] revealed a BIMS could not be completed. Record review of the MDS also revealed the resident has a feeding tube while a resident. Record Review of Resident #119's orders revealed an active order for enteral feeding tube site care since 1/10/25. Record review of Resident #119's care plan with problem start date of 1/20/25 revealed that EBP during tube feeding/wound care or close contact with Enteral feeding site. PPE required: gloves, gowns, face protection if procedure has risk of splashes or sprays. Observation on 3/17/25 at 10:59 a.m. of Resident #119's door, room and hallway revealed that there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 2:15 p.m. of Resident #119's door and hallway revealed that there was no signage regarding enhanced barrier precautions. Observation on 3/18/25 at 3:26 p.m. of Resident #119's door and hallway revealed that there was no signage regarding enhanced barrier precautions. Interview on 3/18/25 at 3:35 p.m., RN K said that Resident #119 should be on enhanced barrier precautions. RN K said there should be a sign on the outside of the resident's door and if it was not there then it must have fallen. Interview on 3/18/25 at 3:42 p.m., CNA H said Resident #119 was on enhanced barrier precautions and she would wear a gown while changing the resident. Interview on 3/18/25 at 3:49 p.m., CNA J said she would know if a resident was on enhanced barrier precautions by the sign on the door. When asked what kind of residents would need to be on enhanced barrier precautions, CNA J said residents who wore briefs or were incontinent. Interview on 3/19/25 at 9:49 a.m., CNA J said she had given the wrong answer yesterday regarding what residents would need to be on enhanced barrier precautions and enhanced barrier precautions were 676155 Page 15 of 16 676155 03/19/2025 The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for residents with g-tubes and a Foley catheter. CNA J said she would wear a gown and gloves and a mask depending on the situation for residents with enhanced barrier precautions. Interview on 3/19/25 at 9:44 a.m., CNA K said that enhanced barrier precautions were everyone who was bedbound, needed barrier cream and rolled every two hours. CNA K said she would know if a resident was on enhanced barrier precautions by the orange sign on the door and she would wear a gown if the resident was on enhanced barrier precautions. Interview on 3/20/25 at 2:52 p.m., the DON said she took note of residents with wounds, foley catheters (tube inserted into the bladder to drain urine), traches (a hole surgically made in the throat to assist with breathing) and feeding tubes which triggered the enhanced barrier precautions. The DON said that in their daily morning meetings they reviewed residents for enhanced barrier precautions. The DON said that when a resident triggered for enhanced barrier precautions then the orange sign was placed on the resident's door and PPE placed in the resident's room. The DON said that then the enhanced barrier precautions was added to the resident's care plan. The DON said that she checked to make sure that the enhanced barrier precautions have been added to the resident's care plan and that PPE was in the resident's rooms. The DON said there was PPE available in the large restroom on the garden side of the facility and PPE is kept in the resident's drawers or armoire on the presidential side of the facility. The DON said she kept track of residents who were on enhanced barrier/isolation precautions using an excel spreadsheet and that she checked and update the spreadsheet every 2-3 weeks. Record Review of facility's Infection Prevention and Control Policies and Procedures with subject Transmission Based/Standard precautions, and Enhanced Barrier Precautions revised 5/15/23 revealed that enhanced barrier precautions which includes the use of gowns and gloves will be implemented during high-contact resident care activities for residents who have wounds and/or indwelling medical devices. Record review also revealed that enhanced barrier precautions will be implemented during high-contact resident care activities that include dressing, bathing/showering, transferring, providing hygiene, changing linens, and changing briefs or assisting with toilet. Record review also revealed The facility will post clear signage on the door or wall outside of the room indicating the type of precautions. 676155 Page 16 of 16