Health inspection·February 29, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination trough support of resident choice for 4 of 24 residents reviewed for resident rights. The facility failed to ensure residents were informed and provided the right to eat in the dining room. This deficient practice could place residents at risk of having their rights violated, poor self-esteem and socialization and a poor quality of life. Findings include: Interview with CNA K on 02/27/2024 at 11:45 AM revealed all residents ate in their rooms for dinner and were not taken to the dining room. CNA K stated she wasn't sure why and some residents requested to eat in the dining room in the past but she wasn't sure which residents. CNA K stated she would be willing to take the residents to the dining room if the facility chose to serve dinner in the dining room. Interview with RN J on 02/27/2024 at 12:55 PM revealed she was assigned to lunch today and residents often ate in the dining room for lunch. RN J stated she worked the 6 AM-6 PM shift and would be assigned to dinner on some days. RN J stated she had not seen any resident go to the dining room for dinner service for a long time, at least more than a year. RN J was not sure if residents were given a choice to go to the dining room for dinner rather than receive a room tray. Interview with [NAME] K on 02/28/2024 at 8:54 AM revealed he worked in the facility for 9 years. [NAME] K stated there was no dinning service in the dining hall and all trays would be pre-plated and pre-portioned in the kitchen and then sent to resident rooms on carts. [NAME] K was not able to answer how long there had been no dining service for evening meals in the facility. In a confidential group, interview revealed the dining room wasn't open in the evenings or on Saturdays due to facility not having enough staff. Four people stated they would like to dine in the dining room or have the option to. Interview with the Dietary Manager on 02/28/2024 at 11:30 AM revealed he worked in the facility for about 3 weeks and had not seen any resident served dinner in the dining room. The Dietary Manager stated he questioned it to himself, about why the residents were not served in the dining room for dinner. The Dietary Manager stated he spoke with the DON about it and the DON stated the dining room Page 1 of 17 676156 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0561 was supposed to be open to all three meals, but was dependent on nurses, CNA's and residents. Level of Harm - Minimal harm or potential for actual harm Interview with the DON and Administrator on 02/28/2024 at 11:55 AM revealed the Dietary Manager had not spoken with them about serving meals in the dining room for dinner service. The DON stated the dining room was always open. The DON could not say how long residents were not eating in the dining room for dinner service. The DON was not able to tell if any residents submitted a grievance about the dinner dining service. The DON stated it was the resident's right to choose where they wanted to eat. The Administrator stated they would revisit how many residents were willing to eat in the dining room and re-educate nursing staff to check with residents. The Administrator stated they took resident rights very seriously and would ensure the residents had freedom to choose where they would like their meals to be served. Residents Affected - Some Interview with the Activities Director on 02/28/2024 at 1:19 PM revealed she heard from residents the facility wasn't using the dining room for dinner service. The Activities Director stated when she heard concerns in Resident Council or if a resident went to her with a concern, then she would let whoever's department that was the subject of the concern know. The Activities Director stated she expected the department the concern applied to, to follow up with the resident. The Activities Director stated sometimes she would let staff know verbally during their morning meetings or when passing in the hall about resident concerns. The Activities Director stated she didn't follow up with residents unless it was a concern regarding her department. The Activities Director stated she communicated the resident's concern of the facility not having the dining room open for dinner service. The Activities Director stated some residents preferred to eat dinner in the dining room. The Activities Director wasn't sure why dinner service did not take place in the dining room and stated she brought the concern to the attention of the Administrator and Dietary Manager. Interview on 02/28/2024 at 4:39 PM with CNA O revealed she thought residents weren't eating in the dining room due to the last wave of COVID in the community, residents wanted to be in their room because they didn't want to get sick. CNA O stated she didn't have to ask some residents if they wanted to eat in the dining room because they usually stayed in their room. Observation on 02/28/2024 revealed one resident sitting in dining room with RN J and another resident sitting at a table with her family member. Interview on 02/28/2024 at 5:08 PM with the resident in the dining room revealed she had been in the facility for about a week and a half. The resident and her family member stated the dining room was usually not opened for dinner, and it was their first time eating in the dining room. Resident stated she enjoyed eating in the dining room for breakfast and lunch to socialize with others. Resident stated they asked about dining in the dining room for dinner but was told the dining room wasn't for dinner. Resident stated she could not recall who told her that the dining room wasn't used for dinner or if they were given a reason why. Resident stated she wasn't sure why the dining room was open for dinner today and was surprised that it was open today. Record review of the facility's, undated, policy titled Resident Rights reflected a resident has a right to participate in activities inside and outside the facility. 676156 Page 2 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review the facility ensure residents had the right to and the facility made prompt efforts to resolve grievances the resident may for 3 of 24 residents (Residents #18, #32, #50) reviewed for resident rights. The facility failed to ensure residents received responses to grievances and concerns. This deficient practice could place residents at risk of having their rights violated, not receive responses to their grievance, a decreased of self-worth and a decline in quality of life. Findings include: 1. Record review of Resident #18's Comprehensive MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included unspecified Dementia, Coronary Artery Disease, Hypertension, Hyperlipidemia and Diabetes Mellitus. Resident #18 had a BIMS score of 10, which indicated moderate cognitive impairment. 2. Record review of Resident #32's Quarterly MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #32's Continuity of Care Document, dated 03/04/2024, reflected diagnoses which included sepsis (blood poisoning), acute kidney failure, hyperlipidemia (high level of fats in blood), and muscle weakness. 3. Record review of Resident #50's Comprehensive MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #50 had diagnoses which included unspecified atrial fibrillation (irregular or rapid heart rhythm), hypertension and Gastroesophageal Reflux disease or ulcer. Resident #50 had a BIMS score of 15, which indicated no cognitive impairment. Record review of the facility's grievance log, dated February 2024, reflected one grievance, dated 02/22/24, with the name of Resident Council and the name of person investigating was the DON. Record review of the facility's grievance log, dated December 2023, reflected one grievance, dated 01/02/23, with the name of resident Resident Council and the name of person investigating was the Administrator. Record review of the grievance log, dated November 2023, reflected one grievance, dated 11/20/23, written by a family member of resident, with the Administrator listed as investigating. Record review of the grievance log reflected no grievances for January 2024, September 2023, and October 2023. Record review of the Resident Council meeting minutes for 02/01/2024 reflected residents requested to speak with the DON. In a document titled Response to Resident Council dated 02/01/2024 from the 676156 Page 3 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administrator reflected the DON would come talk with residents regarding their questions and residents could fill out a [NAME] or speak to DON at any time. Resident council meeting minutes, dated 01/02/2024, reflected for complaints Residents said they have noticed a change in food with a new dietary manager, not bad just different. Record review of the Resident council meeting minutes reflected a document titled Response to Resident Council, dated 01/02/2024 which stated the facility hired a new dietary manager. Record review of Resident Council meeting minutes, dated 12/05/2023, reflected no complaints. In a confidential group interview revealed residents were not aware of how to file a grievance and stated they were not contacted regarding grievances and would not know if their concern was resolved or not. Confidential group interview revealed the Activities Director attended the Resident Council meetings and would write down some concerns, but the residents didn't hear back about the concern. Resident's concerns included resident rights, choices, and customer service. Interview with the Activities Director on 02/28/2024 at 1:19 PM revealed residents did not typically file grievances because they preferred to handle the grievance verbally. The Activities Director stated when she heard concerns in Resident Council regarding a different department other than hers, she would let that department that was the subject of the concern know. The Activities Director stated she expected that department to follow up with the resident. The Activities Director stated sometimes she would let staff know verbally during their morning meetings or when passing in the hall about resident concerns. The Activities Director stated she didn't follow up with residents unless it was a concern regarding her department. The Activities Director stated some examples of concerns she communicated for residents included lack of linen, aides wearing ear buds when on shift, roommate conflict, or the facility not having the dining room open for dinner service. Interview on 02/29/2024 at 10:34 AM with Resident #50 revealed responses to resident concerns did not occur. Resident #50 was asked how a resident knows that the concern had been addressed and Resident #50 stated well, you don't- and quite frankly it usually isn't. Resident #50 stated she would go to ADON I or the Activities Director with her concerns such as aides having an attitude and being rude to her. Resident #50 stated ADON I or the Activities Director response was to verbally tell Resident #50 staff were having a bad day or were joking. Resident #50 stated she was not informed verbally or in writing about any resolution to concerns she had voiced on behalf of herself or other residents. Interview on 02/29/2024 at 10:40 AM with Resident #32, the Resident Council President, revealed residents did not know if concerns were addressed. Resident #32 stated residents would know if a concern was address if they saw a change happen but other than that, they would not know. Resident #32 stated she was not informed verbally or in writing about any resolution to concerns she voiced on behalf of herself or other residents. Interview with ADON I on 02/29/2024 at 10:45 AM revealed she worked at the facility less than a year and the residents had a lot of complaints when she first started working at the facility. ADON I stated most of the concerns were addressed. ADON I stated residents would tell her their concerns verbally. ADON I stated if a resident had a more serious issue, then the resident would fill out a [NAME] form which would step up the attention to the DON or the Administrator. ADON I stated she would also let the DON know verbally, either through morning meetings or by directly speaking to the DON. When asked how residents knew if their issue was resolved, ADON I stated most of the time the 676156 Page 4 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident went to her directly and they would work it out. ADON I stated sometimes residents would forget they had a concern or issue. ADON I stated sometimes a resident would come back to her and tell her they were just having a manic phase. Interview with the DON on 02/29/2024 at 1:00 PM revealed residents preferred to verbally share concerns and the DON would speak with them directly regarding their concern. Interview with the Administrator on 02/29/2024 at 1:08 PM revealed the facility called grievances Mulligans. The Administrator stated their Grievance Log also contained a Compliment Log which they called Hole in One. The Administrator stated they had many more compliments than grievances and residents did not typically fill out grievances. The Administrator stated if it was a serious complaint, she would fill out a grievance on behalf of the resident and most grievances were minor and were handled verbally. The Administrator stated she wasn't sure why residents didn't fill out the grievances. The Administrator stated residents would know if their grievance were followed up on because she would meet with them directly regarding their concern. Record review of facility's, undated, policy titled Resident Rights, reflected residents had the right to complain about care or treatment and receive a prompt response to resolve the complaint without fear of reprisal or discrimination. 676156 Page 5 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible for three of four residents (Residents #20, #8 and #38) reviewed for incontinence and foley catheter care. 1. CNA N failed to provide adequate perineal care for Resident #20, after an incontinent episode, when she failed to ensure all fecal matter was removed from the resident's perineal area. 2. CNA E failed to provide adequate perineal care for Resident #8, after an incontinent episode, when she failed to ensure all fecal matter was removed from the resident's perineal area and failed to clean the residents' buttocks from front to back. 3. The facility failed to ensure Resident #38's catheter bag did not have contact with the floor. These failures could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: 1. Record review of Resident #20's quarterly MDS assessment, dated 01/25/24, reflected a [AGE] year-old female with an admission date of 09/23/20. Resident #20 was severely cognitively impaired with a score of 0, which indicated she was unable to complete the brief interview for mental status. Resident #20 required extensive assistance with all ADLs. The resident was always incontinent of bladder and bowel. The resident's active diagnoses included non-Alzheimer's dementia and Parkinson's disease (disorder of the central nervous system that affects movement). Record review of Resident #20's care plan, initiated on 09/30/22, reflected .Resident experiences bladder and bowel incontinence .Interventions included .apply moisture barrier to skin .report any signs of skin breakdown An observation on 02/27/24 at 01:00 p.m. revealed CNA N and CNA K entered Resident #20's room to transfer her to the bed and perform incontinence care. Both staff washed their hands and put on gloves. CNA N gathered wipes and a clean brief. Both staff attached the mechanical lift sling to the lift and transferred the resident to her bed. CNA N unfastened the resident's brief which revealed she was incontinent of urine and bowel. CNA N took a peri-wipe and wiped down each side of the resident's groin and then wiped down the center of the resident's labia which revealed fecal matter on the peri-wipe. CNA N only wiped the labia area once, and all fecal matter was not removed. CNA N then rolled the resident over on her side, removed her gloves and re-gloved without performing hand hygiene. CNA N continued to wipe the resident's anal area and buttocks from back to front to remove the fecal matter. CNA N reached into the dresser drawer to obtain barrier cream and applied barrier cream while wearing soiled gloves. CNA N changed her gloves without performing hand hygiene and placed a clean brief under the resident. CNA N rolled the resident back on her back with assistance from CNA K, adjusted the resident's gown and bed linens. Both CNAs removed their gloves. CNA N washed her hands and CNA K walked down the hallway to the dirty linen room to dispose of the linen and trash and then 676156 Page 6 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0690 washed her hands. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/27/24 at 01:15 p.m., CNA N stated by not cleaning the resident properly it placed her at risk of skin breakdown and urinary tract infections. She stated she should have wiped the resident with a clean peri-wipe until the wipes were clean, otherwise the resident could still have bowel movement in her vaginal area. Residents Affected - Some Record review of CNA N's competency checks reflected she had been skills checked on proper perineal care on 01/30/24. 2. Record review of Resident #8's quarterly MDS assessment, dated 12/07/23, reflected a [AGE] year-old female with an admission date of 05/10/19. Resident #8 had BIMs of 1, which indicated she was severely cognitively impaired. Resident #8 required extensive assistance with all ADLs. The resident was always incontinent of bladder and bowel. The resident's active diagnoses included Alzheimer's disease. Record review of Resident #8's care plan, initiated on 07/21/23, reflected .Resident has potential for Urinary tract infections related to history of urinary tract infections .Interventions included .If resident is incontinent, provide peri care as soon as possible after incontinent episode per facility policy being sure to cleanse well and cleanse from front to back An observation on 02/28/24 at 12:55 p.m. revealed CNA E and CNA F entered Resident #8's room to transfer her from her Geri chair to the bed and performed incontinence care. Both CNAs washed their hands and put on gloves. Both staff hooked the lift sling to the mechanical lift and transferred the resident to her bed. Both staff removed the resident's pants and unfastened her brief which revealed she was incontinent of urine. CNA E took a separate peri-wipe and wiped down each side of the resident's groin and one time down the middle of her labia without checking to see if the wipe was clean. CNA E rolled the resident over on her side pushed the wet brief and wipes used to clean her front under the resident. CNA E removed her gloves and stated she forgot her hand sanitizer and put on clean gloves. CNA E then wiped the resident's anal area from front to back which revealed a small smear of fecal matter. CNA E did not wipe the resident's buttocks or upper thighs before she placed a clean brief under the resident. CNA E changed her gloves but did not perform hand hygiene and applied barrier cream to the residents' buttocks and then rolled her onto her back and applied barrier cream to the residents' groin area. Both staff fastened the resident's brief and adjusted her linens. Both staff then removed their gloves and washed their hands. In an interview on 02/28/24 at 01:10 PM, CNA E stated she knew she was supposed to perform hand hygiene after each glove change but had forgot her hand sanitizer. She stated she should have washed her hands. She stated when they did incontinent care, they were supposed to wipe the entire buttocks and top of the thighs to make sure the residents were clean. She stated she should also make sure there was no fecal matter in the resident's vaginal area. She stated not doing it correctly placed the resident at risk of infections and skin breakdown. Interview with the DON on 02/28/24 at 02:10 p.m. revealed when incontinent care was provided staff were to clean from front to back, cleaning the peri area then moving toward the buttocks. She said they needed to wipe the area with a clean peri-wipe until all fecal matter and urine was removed. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. 676156 Page 7 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of CNA E's competency checks reflected she had been skills checked for proper perineal care on 10/30/23. 3. Record review of Resident #38's Annual MDS assessment, dated 12/18/2023, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: neurogenic bladder (urinary conditions in patients who lack bladder control related to brain or nerve problem), Cerebrovascular accident (brain damage from interruption of blood supply), hypertension (high blood pressure), hyperlipidemia (high levels of lipids in blood) and non-Alzheimer's dementia. She was always incontinent of bowel and had a Foley catheter. Record review of Resident #38 active Physician order reflected Foley Catheter care every shift with soap and water, with a start date of 09/09/22. Record review of Resident #38's comprehensive care plan, dated 12/19/2023, reflected Resident #38 had a foley catheter and was at risk for increased urinary tract infections. Goal: Foley will remain patent with no signs and symptoms of UTI. Approach: Catheter Care per orders. An observation on 02/27/24 at 10:57 a.m. revealed Resident #38 lying in the bed and the foley catheter bag was in contact with the floor. Interview with CNA K on 02/27/24 at 11:20 a.m. revealed the catheter bag should always hang on the side of the bed. She stated the CNA or nurses were responsible for emptying the bag. She was assigned to the resident but did not empty the bag this morning since it was already empty. She did not see the catheter bag on the floor until the time of this interview. She stated if the catheter bag was on the floor it could lead to increased risk of infections. Interview with RN J on 02/27/2024 at 11:40 a.m. revealed the catheter bag should never touch the floor because of increased risk of infection. She stated she was assigned to the resident and did not see the catheter bag on the floor until the time of this interview. She stated the nurses were responsible for changing the catheter bag and CNAs or Nurses could empty the catheter bag. In an interview with the DON on 2/28/24 at 3:07 p.m. revealed her expectation was the catheter bag should always be off the ground and below the resident's bladder, per nursing standards. She stated the risk for having a catheter bag in contact with the floor was increased risk for infections. Record review of the facility's policy titled, Perineal Care, dated February 2018, reflected .Wash and dry hands thoroughly .put on gloves .For a female resident .Wash perineal area, wiping from front to back .Separate labia and wash area downward from front to back .Continue to wash the perineum area from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and clean washcloth .Gently dry perineum .Wash the rectal area thoroughly wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly .Remove gloves .Wash and dry your hands Record review of the facility's policy titled, Catheter Care, Urinary, dated August 2022, reflected .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor 676156 Page 8 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #13) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #13's nasal cannula tubing was labeled or dated. This failure could place residents at risk of respiratory infections. The finding were: Record review of Resident #13's Annual MDS assessment, dated 1/14/2024, reflected Resident #13 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13's relevant diagnoses included Stroke, Chronic Obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), Diabetes mellitus (high blood sugar levels) and Hyperlipidemia (high levels of lipid in blood). Resident #13 was on oxygen therapy. Record review of Resident #13's comprehensive care plan, dated 1/15/2024, reflected Resident #13 was on oxygen therapy for episodes of Shortness of Breath and was at risk for respiratory distress or failure and the resident had oxygen at 1-4 Liter per minute via nasal cannula and apply oxygen per order, encourage the resident to take slow and deep breaths. Record review of Resident #13 Physician order, dated 1/11/2024, reflected continuous oxygen at 1 - 4 Liter per minute via nasal cannula every shift, day or evening. Record review of Resident #13 Physician order, dated 1/14/2024, reflected change oxygen tubing and humidifier bottle weekly (when in use) once a day on Sunday or as needed on night shift. Observation on 02/27/24 at 11:11 AM revealed Resident #13 was on oxygen therapy and the nasal cannula tubing was not labeled or dated. In an interview with RN J on 02/27/2024 at 11:39 AM revealed all oxygen delivery equipment which included oxygen tubing and humidifier bottle should be dated and labeled. She reported oxygen nasal cannula tubing was to be changed on the night shift every Sunday and nurses were responsible for changing and dating the tubing. She stated not dating and labeling nasal cannula tubing could lead to infection control issues. She also stated she would change the nasal cannula tubing immediately. In an interview with the DON on 2/28/24 at 3:07 PM revealed it was her expectation to label and date all oxygen equipment. She stated it was done by Night shift nurses on a weekly basis. The risk of not dating nasal cannula tubing could lead to lapses in infection control and it was nursing protocol to date all medical equipment a resident used. Record review of the facility's policy for oxygen administration, revised October 2010, reflected Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 676156 Page 9 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

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 for the facility's only kitchen. Residents Affected - Many 1. The facility failed to date food stored in the walk-in refrigerator. 2. The facility failed to date food stored in the walk-in freezer . 3. The facility failed to cover and date food in the dry storage. 4. The facility failed to sanitize the food thermometer while measuring entrée temperatures. These failures could place residents who at risk for food-borne illness and food contamination. Findings included: Observation in facility's kitchen on 02/27/24 at 09:51 AM revealed hard boiled eggs in the walk-in refrigerator were not dated. Observation in facility's kitchen on 02/27/24 at 09:53 AM revealed a bag of frozen mixed vegetables in the walk-in freezer was not dated. Observation in facility's kitchen on 02/27/24 at 09:56 AM revealed a packet of Taco shells was left opened, uncovered, and undated in a box. Observation in facility kitchen on 02/28/2024 at 11:15 AM revealed [NAME] L did not use sanitizer wipes to clean the food thermometer while measuring food temperatures between 2 food entrees on the steam table. [NAME] L checked the temperature of the chicken entrée, looked for the alcohol-based sanitizing wipes and then asked the Dietary Manager to bring some wipes since she was out of it. While waiting for the wipes, [NAME] A proceeded to wipe the food thermometer with a paper towel and inserted the thermometer into beef patties. With State Surveyor intervention, [NAME] L then cleaned the thermometer with a sanitizing wipe before proceeding to measure the temperature for other entrees on the steam table. In an interview with [NAME] L on 02/28/24 at 8:54 AM revealed she worked in the facility for 9 years. She stated all food items in the kitchen needed to be dated and labeled; so food items could be used based on their dates. She also stated usually the cooks who received the food items were responsible for dating and labeling food items. She stated she had not worked the previous day and hence 676156 Page 10 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many she did not know who had left the taco shells opened, undated and uncovered in the dry storage. She revealed if she were to find any food items that were not dated or covered appropriately, she would throw away the item and inform the Dietary Manager. She stated the risk of not dating food items or covering food items could lead to food borne illness. In an interview with [NAME] L on 2/28/2024 at 11:20 AM, she stated that she knew the food thermometer needed to be wiped off with a sterile alcohol pad to prevent cross contamination. However, because she ran out of the wipes, she did not want to wait and decided to use the paper towel instead. She stated it was her mistake to use it. She also stated cross contamination of foods could ultimately lead to food borne illness. In an interview with the Dietary Manager on 02/28/24 at 11:35 AM revealed he was new to the facility and started working in the facility 3 weeks ago. He revealed all food items needed to be dated, labeled, and covered appropriately. He stated frozen veggies were delivered 2 weeks ago and should have been dated. He stated taco shells were used on 2/26/24 for a meal and the cook must have forgotten to cover and date it. He revealed cooks were responsible for dating all food items, as well as covering them. The standard practice in the kitchen was to wipe the food thermometer with an alcohol-based sanitizing wipe between entrees while measuring temperatures. He stated his expectation was all food items should be label, dated and always covered and he would provide an in-service to the kitchen staff regarding safe food handling and proper temperature measurement techniques. He revealed the risk for not dating or covering food items and failure to use sanitizing wipes for wiping down the food thermometer could lead to food contamination and food borne illness. Record review of the facility's Refrigerator and Freezers policy, revised December 2019, reflected .all foods should be appropriately dated to ensure proper rotation by expiration dates .Expiation dates on unopened food will be observed and 'use by' dates indicated once food is opened. Record review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Record review of the Food and Drug Administration Food Code, dated 2022, reflected, .4-302.12 Food Temperature Measuring Devices (vi) Temperature measuring device probes must be sanitized to prevent contaminating products when internal temperatures are measured. 676156 Page 11 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

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 six (Resident #11, Resident #113, Resident #42, Resident #114, Resident #20, and Resident # 8) of ten residents observed for infection control. Residents Affected - Some 1. LVN A failed to decontaminate the glucometer which was used to obtain a fingerstick blood sugar on Resident #11 when she failed to allow the glucometer that was sanitized with a germicidal wipe to air dry before returning the glucometer to the medication cart. 2. LVN A failed to prevent cross contamination of Resident #11's insulin and a bottle of test strips, used to obtain glucose levels, when she carried both items into Resident #11's room. 3. LVN D failed to prevent cross contamination of a bottle of test strips, used to obtain glucose levels, when she carried the bottle into Resident #113's room and opened the bottle to retrieve a test strip while wearing soiled gloves. 4. LVN C failed to sanitize the blood pressure cuff between uses on Resident #42. 5. LVN B failed to prevent cross contamination of Resident # 114's medication when she spilled two of his medication onto the medication cart and picked them up with her bare hands and placed them back with the remainder of his medications. LVN B failed to sanitize the blood pressure cuff, pulse oximeter and thermometer after use on resident #114. 6. CNA N failed to perform hand hygiene during incontinence care for Resident #20. 7. CNA K failed to ensure soiled linens were placed in a plastic bag before placing them on boxes in Resident #20's room and failed to perform hand hygiene prior to leaving the resident's room. 8. CNA E failed to perform hand hygiene during incontinence care for Resident # 8. Theses failure could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #11's, undated, face sheet reflected an [AGE] year-old female with an admission date of 02/22/24. Resident #11 had a diagnosis which included Type 2 diabetes. An observation on 02/27/24 at 11:25 a.m. revealed LVN A at the medication cart preparing to perform Resident #11's finger stick blood sugar. LVN A removed the glucometer from the medication cart, lancet, a bottle of test strips from the top of the medication cart and Resident #11's box of insulin, a syringe and needle and performed hand hygiene and donned gloves. LVN A entered the resident's room and placed the items on Resident #11's bedside table without cleaning the table or placing the items on a barrier. LVN A opened the bottle of test strips and placed a test strip into the glucometer and pricked Resident #11's finger and obtained a blood sample. LVN A placed the glucometer with the blood sample back onto the resident's bedside table, removed her gloves and returned to the computer 676156 Page 12 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to check the amount of insulin the resident would require. LVN A performed hand hygiene and put on gloves and re-entered the resident's room. LVN A picked up the insulin box and removed the vial of insulin and drew up the required amount of insulin and placed the bottle of insulin on the bedside table and administered the insulin to the resident. LVN A placed the insulin back in the insulin box, wearing soiled gloves, picked up the glucometer and placed it in a plastic cup and placed the bottle of test strips in the cup with the dirty glucometer and returned to the medication cart. LVN A disposed of the syringe, needle, lancet and test strips and placed the bottle of bottle of test strips in a basket with lancets and supplies without sanitizing it. LVN A opened the medication cart and put the resident's box of insulin back in the medication cart with other resident's boxes of insulin. LVN A pulled out a germicidal wipe with a 3-minute kill time (the time needed to kill all bacteria) and wiped down the glucometer. LVN A immediately placed the glucometer back in the medication cart without letting the glucometer air dry. In an interview with LVN A on 02/27/24 at 11:40 a.m., she stated she was not sure how long the contact time was for the germicidal wipe she used to clean the glucometer. LVN A reviewed the contact time on the EPA approved germicidal wipe and determined it was for 3 minutes. She stated by not letting the glucometer air dry there was the potential for cross contamination and could potentially expose residents to blood borne pathogens. LVN A stated any disposable supplies carried into the resident's room were considered contaminated. She stated she should not have taken the bottle of test strips or the insulin into the room. She stated she was thinking of all the things she might need to complete the process, but then realized she had cross contaminated several of the items. She stated by doing this it created a risk of infections and the spread of germs to other residents. 2. Record review of Resident #113's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #113's had a diagnosis which included Type 2 diabetes. An observation on 02/27/24 at 11:45 a.m. revealed LVN D at the medication cart preparing to obtain a fingerstick blood sugar on Resident #113. LVN D gathered a glucometer, lancet, alcohol wipes and a bottle of test strips. LVN D performed hand hygiene and put on gloves. LVN D carried in the bottle of test strips into the room with the other items and placed them on the resident's bedside table without cleaning the table or placing the items on a barrier. LVN D pricked the resident finger to obtain a blood sample then opened the bottle of test strips while wearing the same gloves and placed a test strip into the glucometer to obtain the blood sugar reading. LVN D removed her gloves and returned to the medication cart with the glucometer and the bottle of test strips and placed the bottle of test strips in a basket with other supplies on top of her medications cart and laid the glucometer on a paper towel. LVN D then checked the computer to determine the amount of insulin needed. LVN D then retrieved a germicidal wipe and wiped down the glucometer and placed it back on the same paper towel and then wiped down the bottle of test strips and placed them back in the basket of supplies. LVN D then performed hand hygiene, retrieved the insulin, drew up the amount required and administered the insulin to the resident. In an interview with LVN D on 02/27/24 at 11:50 a.m., she stated she was supposed to perform hand hygiene after glove removal before the procedure and after the procedure. She stated by taking in the bottle of test strips into the room it had the potential for cross contamination. She stated she should have a clean field for supplies and for the glucometer after she had cleaned it. She stated placing the bottle of test strips in with the other supplies before she sanitized it could cross contaminate the supplies. 3. Record review of Resident #42's, undated, face sheet reflected an [AGE] year-old female with an 676156 Page 13 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission date of 10/14/22. Resident #42 had a diagnosis which included Crohn's disease (inflammatory bowel disease). During a medication pass observation and interview on 02/28/24 at 07:10 a.m. revealed LVN C left Resident #31's room with a wrist blood pressure cuff in her hand. LVN C placed the wrist cuff on top of the medication cart and stated she was going to the next hall for medication pass. LVN C performed hand hygiene and put on gloves and entered Resident #42's room and obtained her blood pressure with the un-sanitized blood pressure cuff. LVN C returned to the medication cart and placed the un-sanitized blood pressure cuff on top of the medication cart. LVN C removed her gloves and performed hand hygiene and proceeded to pull the resident's a.m. medication. In an interview with LVN C on 02/28/24 at 07:40 a.m., she stated she was supposed to sanitize the blood pressure cuff after each resident, and she failed to do that. LVN C then opened the medication cart to retrieve the germicidal wipes and could not locate any wipes. She stated someone took the wipes off her cart and she would get more wipes and sanitize the blood pressure cuff before the next resident. She stated failure to sanitize the blood pressure cuff placed residents at risk for the spread of germs. 4. Record review of Resident #114's, undated, face sheet reflected an [AGE] year-old-male with an admission date of 02/26/24. Resident #114 had diagnoses which included specified injury of right quadricep muscle (group of four muscles that cover the front and sides of the thigh) and fracture of right patella (kneecap). During a medication pass observation on 02/28/24 at 07:50 a.m. revealed LVN B at the medication cart. LVN B obtained a blood pressure cuff, pulse oximeter and electronic thermometer and entered Resident #114's room to obtain his vital signs. LVN B placed the pulse oximeter on the resident's finger and placed the blood pressure machine on the resident's bed and wrapped his arm with the blood pressure cuff and took his blood pressure reading. LVN B then scanned his forehead with the thermometer and removed the pulse oximeter and returned to the medication cart and placed the thermometer and pulse oximeter back inside the medication cart and the blood pressure machine on top of the cart without sanitizing any of the items. LVN B then sanitized her hands and started pulling the residents medications. LVN B had two pills in a plastic cup when she accidently knocked the cup over spilling the 2 pills on top of the medication cart. LVN B picked up the pills with her bare hands and placed them back in the mediation cup and continued pulling the remainder of Resident #114's a.m. medications. LVN B then entered Resident #114's and administered his medications. In an interview on 02/28/24 at 08:00 a.m. with LVN B, she stated she should have used a glove to pick up the pills. She then stated she should have discarded the pills since the surface of the medication cart was considered dirty and the medication was considered contaminated. She stated the equipment was supposed to be sanitized after each use and by putting the unclean items back in the cart she posed the risk of cross contamination. In an interview with the DON on 06/14/22 at 2:25 p.m., she stated staff needed to make sure all equipment, blood pressure cuffs, pulse oximeters, thermometers and glucometers were cleaned with appropriate germicidal wipes between resident use especially glucometers. She stated the glucometers had to remain visibly wet for the appropriate contact time for the glucometer to be considered sanitized. She stated they should always let them air dry and should not place them back into the cart until they were dry. She stated this failure placed residents at risk of the spread of germs and cross contamination. She stated staff should not carry in the resident's whole vial of insulin or the whole 676156 Page 14 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bottle of test strips since test strips were for multiple resident use. She stated the staff should only carry in the supplies needed to complete the blood sugar, and then return to the cart to obtain the needed insulin. She stated staff were to always perform hand hygiene during medication pass, before and after glove removal. She stated if a medication was dropped or spilled it should be discarded since it would be considered contaminated. She stated these failures placed residents at risk of cross contamination and the spread of infection. Record review of the facility's polity titled, Cleaning and Disinfecting Non-critical Resident-Care Items, dated June 2011, reflected .The following categories are used to distinguish the levels of sterilization/disinfection necessary for times used in resident care . non-critical items are those that come in contact with intact skin but not mucous membranes. Such items include .blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents .Intermediate and low-level disinfectants for non-critical items include .Sodium hypochlorite (germicidal wipes) Record review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, dated October 2011, reflected, .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . obtain a blood sample by using a sterile lancet .Discard disposable supplies in the designated containers .Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice Review of CDC guidelines, obtained on 03/04/24, reflected https://www.cdc.gov/cliac/docs/addenda/cliac0313/07B_CLIAC_2013March_Glucose_Monitoring.pdf, reflected, .The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose ( blood sugar) monitoring and insulin administration .Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put person at risk for infection include .Failing to change gloves and perform hand hygiene between fingerstick procedures .A simple rule for safe care .Blood glucose Meters .disinfected after every use .General .unused supplies and medications should be maintained in clean areas separate from used supplies and equipment .Do not carry supplies and medications in pockets .Hand hygiene .Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other person's 5. Record review of Resident #20's quarterly MDS assessment, dated 01/25/24, reflected a [AGE] year-old female with an admission date of 09/23/20. Resident #20 was severely cognitively impaired with a score of 0, which indicated she was unable to complete a brief interview for mental status. Resident #20 required extensive assistance with all ADLs. The resident was always incontinent of bladder and bowel. The resident's active diagnoses included non-Alzheimer's dementia and Parkinson's disease (disorder of the central nervous system that affects movement). An observation on 02/27/24 at 01:00 p.m. revealed CNA N and CNA K entered Resident #20's room to transfer her to bed and perform incontinence care. Both staff washed their hands and put on gloves. Both staff attached the mechanical lift sling to the lift and transferred the resident to her bed. Both staff rolled the resident from side to side to remove the sling and draw sheet. CNA K placed the sling and draw sheet on top of a box of supplies in the corner of the resident's room without placing them in a plastic bag. CNA N unfastened the resident's brief which revealed she was incontinent of urine and bowel. CNA N took a peri-wipe and wiped down each side of the resident's groin and then wiped down the center of the resident's labia which revealed fecal matter on the peri-wipe. CNA N only wiped the labia area once, and did not remove all the fecal matter. CNA N rolled the resident over on her side, removed her gloves and re-gloved without performing hand hygiene. CNA N continued to 676156 Page 15 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wipe the resident's anal area and buttocks from front to back to remove the fecal matter. CNA N reached into the dresser drawer to obtain barrier cream and applied barrier cream while wearing the soiled gloves. CNA N changed her gloves without performing hand hygiene and placed a clean brief under the resident. CNA N then rolled the resident back on her back with assistance from CNA K, adjusted the resident's gown and bed linens. Both CNAs removed their gloves. CNA N washed her hands and CNA K walked down the hallway to the dirty linen room to dispose of the linen and trash and then washed her hands. In an interview on 02/27/24 at 01:15 p.m., CNA N stated by not cleaning the resident properly it placed her at risk of skin breakdown and urinary tract infections. She stated she should have wiped the resident with a clean peri-wipe until the wipes were clean, otherwise the resident could still have bowel movement in her vaginal area. In an interview with CNA K on 02/27/21 at 1:20 p.m., she stated they were supposed to place all soiled linens in a plastic bag and not lay them on any surface without placing them in a bag. She stated she was supposed to perform hand hygiene before she left the resident's room. She stated failing to do this could spread infections. Record review of CNA N's competency checks reflected she had been skills checked on proper perineal care on 03/23/23, which included performing hand hygiene. Record review of CNA K's competency checks reflected she had been skills checked on proper perineal care on 07/24/23, which included performing hand hygiene. 6. Record review of Resident #8's quarterly MDS assessment, dated 12/07/23, reflected a [AGE] year-old female with an admission date of 05/10/19. Resident #8 had a BIMs of 1, which indicated she was severely cognitively impaired. Resident #8 required extensive assistance with all ADLs. The resident was always incontinent of bladder and bowel. The resident's active diagnoses included Alzheimer's disease. An observation on 02/28/24 at 12:55 p.m. revealed CNA E and CNA F entered Resident #8's room to transfer the resident from her Geri chair to the bed and perform incontinence care. Both CNAs washed their hands and put on gloves. Both staff hooked the lift sling to the mechanical lift and transferred the resident to her bed. Both staff removed the resident's pants and unfastened her brief which revealed she was incontinent of urine. CNA E took a separate peri-wipe and wiped down each side of the resident's groin and one time down the middle of her labia without checking to see if the wipe was clean. CNA E rolled the resident over on her side and pushed the wet brief and wipes used to clean her front under the resident. CNA E removed her gloves and stated she had forgot her hand sanitizer and put on clean gloves. CNA E wiped the resident's anal area from front to back which revealed a small smear of fecal matter. CNA E did not wipe the resident's buttocks or upper thighs before she placed a clean brief under the resident. CNA E changed her gloves but did not perform hand hygiene and applied barrier cream to the residents' buttocks and rolled her onto her back and applied barrier cream to the residents' groin area. Both staff fastened the resident's brief and adjusted her linens. Both staff removed their gloves and washed their hands. In an interview on 02/28/24 at 01:10 PM, CNA E stated she knew she was supposed to perform hand hygiene after each glove change but had forgot her hand sanitizer. She stated she should have washed her hands. She stated when they did incontinent care, they were supposed to wipe the entire buttocks and top of the thighs to make sure the residents were clean. She stated she should also make sure 676156 Page 16 of 17 676156 02/29/2024 Prestonwood Rehabilitation & Nursing Center Inc 2460 Marsh LN Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some there was no fecal matter in the resident's vaginal area. She stated not doing it correctly placed the resident at risk of infections and skin breakdown. Interview with the DON on 02/28/24 at 02:10 p.m. revealed when providing incontinent care staff were to clean from front to back, cleaning the peri area then moving toward the buttocks. She said they needed to wipe the area with a clean peri-wipe until all fecal matter and urine was removed. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. Record review of CNA E's competency checks reflected she had been skills checked for proper perineal care on 12/27/22, which included performing hand hygiene. Record review of the facility's policy titled, Perineal Care, dated February 2018, reflected, .Wash and dry hands thoroughly .put on gloves .For a female resident .Wash perineal area .Gently dry perineum .Wash the rectal area .Rinse and dry thoroughly .Remove gloves .Wash and dry your hands Record review of the facility's policy titled, Handwashing/Hand Hygiene dated August 2019, reflected, The facility considers hand hygiene the primary means to prevent the spread of infection .Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled .Use an alcohol-based hand rub .for the following situations .before and after direct contact with residents Before handling medications .before donning gloves .Before moving from a contaminated body site to a clean body site during resident care .After contact with a resident's intact skin .after contact with blood or bodily fluids After contact with objects (medical equipment) in the immediate vicinity of the resident .after removing gloves 676156 Page 17 of 17