Health inspection·January 10, 2024

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to employ a qualified social worker on a full-time basis, in that; Residents Affected - Some The Social Service's Director was not supervised for a year which made her not a qualified social worker. Operation Manager revealed, she was aware of the requirement to have a social worker however, she did not realize the capacity exceeded the number for a licensed social worker. This failure could affect residents of the facility by placing them at increased risk of psychosocial decline and poor-quality of life. Findings included: Record review of the facility's Social Service's Director Employee File revealed a hire date of 07/05/22. File did not indicate a college degree or license. In an interview on 01/10/24 at 1:15 PM at Social services Director revealed, she has been in the position for a year. The Social Services Director stated she graduated in 2014 from Texas A&M commerce with bachelor's in social work. Social services director revealed, she done collaboration with the other social workers at the sister facilities. The Social Service Director stated it is important to have a licensed to work in the facility to take on liability for protection for the residents. The Social services Director revealed, the social worker should be licensed to work in the facility, aware of the code of ethics and general knowledge, and to demonstrate that you are competent to be a social worker and provide services to the residents and their families. In an interview on 01/10/24 at 1:28 PM the Operation Manager revealed, she was aware of the requirement to have a social worker however, she did not realize the capacity exceeded the number for a licensed social worker. Social worker for the sister facility consulted with her and did orientation. Operation Manager revealed she did not believe it put the residents at risk by not having a licensed social worker. Operations Manager revealed they prefer the social worker to be licensed to make it better for residents and self-development. Operation Manager revealed Social Services Director will be taking her licensed exam in February. In an Interview on 01/10/24 at 2:00 pm with social worker from sister facility revealed, she did orientation with the Social Services Director. Social Worker from sister facility revealed she had gone over with the Social Services Director on how to assist residents and family. The Social Worker from sister facility revealed, she is not a supervisor but, she is available to assist her when she Page 1 of 3 676188 676188 01/10/2024 Millbrook Healthcare and Rehabilitation Center 1850 W Pleasant Run Rd Lancaster, TX 75146

F 0850 needs help. Level of Harm - Minimal harm or potential for actual harm No policy was received for a social worker job description by operation Manager before exiting the facility. Residents Affected - Some 676188 Page 2 of 3 676188 01/10/2024 Millbrook Healthcare and Rehabilitation Center 1850 W Pleasant Run Rd Lancaster, TX 75146

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 one of five residents (Resident #23) reviewed for infection control. Residents Affected - Few MA A dropped medication on the medication cart and then picked the medications without gloves and administered to Resident #23 on 01/08/24. These failures could place residents at risk for contamination and infection. The findings included. Observation on 01/08/24 at 10:40 AM reflected MA A preparing the medications for Resident #23 and putting them in the medication cart. Then the MA A when reaching out knocked the medication cup leading to medication falling on the medication cart. MA A then without gloves picked up the medications off the medication cart and placed them back in the medication cart and then administered to Resident #23. In an interview on 01/08/24 at 10:45 AM with MA A she stated when the medications fell on the medication cart, she was not supposed to administer the medications to the resident. MA A stated the cart was considered dirty and she was supposed to use gloves when touching resident medications because her hands were not considered clean. MA A stated she was not to administer medications because the medications were not clean, and she was supposed to use gloves to prevent cross contamination. MA A stated she had been in-serviced about one month ago on infection control. In an interview on a01/10/2t 4 01:01 PM with ADON she stated the MA A was not supposed to pick medications off the cart without gloves and administer the medications to the resident because they were assumed not clean. ADON stated the MA A was supposed to discard the medications due to infection control. ADON stated MA A had been in-serviced on infection control last week. In an interview on 01/10/24 at 01:30 PM with the Operations Manager she stated MA A informed her on Monday that she had messed up. The MA A informed the Operations Manager she had touched the resident's medications without gloves. The Operational Manager stated the MA A was supposed to throw away the medications that fell on top of the medication cart and use gloves when handling resident's medications for infection control. Review of the facility policy revised 07/2014 and titled Hand Washing reflected, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.Hand washing/ hand hygiene is generally considered the most important single procedure for preventing the transmission of infection. 676188 Page 3 of 3