Health inspection·July 22, 2022

F 0686 Level of Harm - Minimal harm or potential for actual harm extremities, HTN, CVA with Hemiplegia, Colostomy status, urinary retention, Foley Catheter in place, draining clear yellow urine and other medical conditions. head to toe assessment completed with V/S. medication verification with NP completed. order entry completed. DON notified. treatments initiated. re-oriented to staff, room, bed controls and routine. he denied pains and discomfort at this time and no s/s of distress. will continue to monitor. Written by: LVN G Residents Affected - Few Record review of the Resident #20's progress note dated 7/8/2022 15:32 revealed Skin/Wound Note Text: Resident assessed and noted with multiple wounds. Left heel DTI, left lateral ankle stage 4 approximately 2.0 x 2.8 x 0.5, left lateral lower leg unstageable wound approximately 5.0 x 1.5, left scapula unstageable wound approximately 5.5 x 2.4, right thigh open blister approximately 4.0 x5.4 x 0.1, right proximal and distal lower leg unstageable wounds, right heel stage 2 approximately 4.0 x 1.8 x 0.1, right ischial stage 4 approximately 6.4 x 4.4 x 2.4, sacra stage 4 approximately 9.5 x 7.5 x 2.3. Dr. [physician name] wound care MD was notified and orders given. All wounds were cleanse and dressing applied. Resident reposition for comfort and no c/o at this time. Will continue to monitor. Written by: LVN B. Record review of Resident #20's Physician Orders dated 07/2022 revealed Cleanse heel with NS/WC, pat dry, apply skin prep and leave OTA daily. Every day shift for wound care. Start date 7/9/22. Cleanse left lateral lower leg and right proximal, distal lower leg with NS/WC, pat dry, apply santyl and calcium alginate and cover with dry dressing daily. Every day shift for wound care. Start date 7/09/22. Cleanse right heel and thigh with NS/WC, pat dry, apply collagen and cover with dry dressing daily. Every day shift for Wound care. Start date 7/09/22. Cleanse sacral, right ischial and left lateral ankle with NS/WS, pat dry, apply silver alginate and cover with dry dressing daily. Every day shift for Wound care. Start date 7/09/22. Record review of Resident #20's MAR/TAR dated 07/2022 revealed no wound care documented on 07/16/22, 07/17/22, and 07/20/22 for: 1. Cleanse heel with NS/WC, pat dry, apply skin prep and leave OTA daily. Every day shift for wound care. 2. Cleanse left lateral lower leg and right proximal, distal lower leg with NS/WC, pat dry, apply santyl and calcium alginate and cover with dry dressing daily. 3. Cleanse right heel and thigh with NS/WC, pat dry, apply collagen and cover with dry dressing daily. Every day shift for Wound care. 4. Cleanse sacral, right ischial and left lateral ankle with NS/WS, pat dry, apply silver alginate and cover with dry dressing daily. Every day shift for Wound care. Record review of Resident #20's Physician orders dated 07/2022 revealed: Skin Assessment, Complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 skin and wound assessment every day shift every Tuesday. Order date 7/12/22, start date 7/19/22. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #20's Skin and Wound Evaluation documents revealed his last skin/wound evaluation was completed on 07/11/22. Residents Affected - Few Observation and interview on 07/21/22 at 10:31 AM revealed Resident #20 was lying in bed with pillow under his left side. Resident was in a low bed. Resident #20 stated he did not get wound care yesterday (07/20/22). He said he was given a shower and the staff did not make sure he got his wound care. Observation of wound care of Resident #20's by LVN B revealed: 1-Observation on 07/21/22 at 11:16 AM revealed left ankle wound dressing removed. Dressing was dated 7/19/22. Wound cleaned with wound cleanser, dried silver alginate applied and redressed. 2-Observation on 07/21/22 11:21 AM revealed left calf dressing removed. Dressing was dated 7/19/22. Small healing wound almost completely closed. Collagen applied redressed. 3-Observation on 07/21/22 11:25 AM revealed left heel area open to the air, skin prep applied. 4-Observation on 07/21/22 11:29 AM revealed Right heel dressing removed dated 7/19/22. Small healing wound collagen applied and Redressed. 5-Observation on 7/21/22 11:33 AM revealed Left shoulder blade wound dressing removed. Dressing was dated 7/19/22. Wound cleaned with santyl and Ca++ alginate applied redressed. 6-Observation on 7/21/22 11:44 AM revealed large open sacral wound with foul smelling Serosanguinous drainage. The dressing was saturated and undated. Wound cleaned with wound cleanser, santyl and Ca++ applied lightly packed with dry gauze. Dry dressing applied. 7-Observation on 07/21/22 11:54 AM revealed open right Ischial wound dressing saturated and undated. Wound cleaned with wound cleanser, santly and Ca++ applied lightly packed with gauze and Redressed. 8-Observation on 7/21/22 12:03PM revealed open blister to right thigh dressing removed dated 7/19/22. Area cleaned with skin cleanser, collagen applied and redressed. 9-Observation on 7/21/22 12:10 PM revealed right calf wound dressing was undated. Wound cleaned with wound cleanser, Santyl and Ca++ applied dry dressing. In an interview on 07/21/22 at 10:34 AM, LVN A stated she did not do Resident #20's wound care the previous day (07/20/22). Resident #20 was getting a shower and she was about to leave the facility, she got off at 6pm. The 6pm nurse (LVN E) was supposed to complete the wound care. She told the 6pm nurse to do wound care. Surveyor attempted to contact LVN E on 07/21/22 at 11:58 AM, left voicemail message. No call returned. In an interview on 07/21/22 at 12:35 PM, LVN A stated all wound care for Resident #20 was supposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to be completed daily. The dressing was supposed to be dated for all wounds. She thought LVN B who used to be the wound care nurse was supposed to do the wound care. LVN B worked the floor yesterday. She said she was not aware LVN B was not doing wound care. The DON was responsible for setting the schedule and making sure assignments were communicated. On the MAR/TAR they have sections for the nurse and the med aide to complete. Wound care had its own tab that the wound care nurse would complete. The wound care nurse would go under that tab and document the completion of wound care. It was important to perform wound care daily so the resident's wound will not get infected, it was important to date the dressing so the nursing staff will know the wound care had been completed. Resident #20 was on antibiotics for infection. In an interview on 07/21/22 at 1:44 PM, LVN B stated she was not the wound care nurse, the nurses on the floor were supposed to complete their own wound care. She said she was not sure why Resident #20 did not have his wound care yesterday. The nurses on the floor were supposed to complete their own skin assessments and wound evaluations. It was important to complete the skin assessments and document the date on the dressing, so the nursing staff know that the dressing had been changed. The wound care should be completed daily, and staff are supposed to follow the physician orders. The tab on the TAR notified the nurses they are supposed to complete wound care. In an interview on 07/21/22 at 2:34 PM, LVN D stated she completed the wound care on the weekend. She said she forgot to document on 07/16/22 and 07/17/22. She said that the rule was if it was not documented it was not done. Some time she had another nurse complete the documentation. Wound care orders are supposed to be completed daily or as ordered. The dressing should be dated after wound care. It was important to complete wound care as ordered to prevent infection and promote wound healing. It was important to document the date on the dressing, so staff know that the wound care was completed. In an interview on 07/21/22 at 11:27 AM, the DON stated there was a lack of communication between her and the previous wound care nurse, LVN B. The previous wound care nurse completed the wound evaluations on Mondays, but she thought they were done on Thursday or Friday after wound doctor completed his assessment. As of last Friday, the facility switched over to the ADON because the wound care nurse did not want to do the wounds anymore. The ADON will oversee wound care and the floor nurses will do wound care. The ADON was out due to a personal matter. The ADON was supposed to be monitoring the wound evaluations per the Performance Improvement Action Plan. Record review of the facility Performance Improvement Action Plan dated 05/01/2022 revealed .Topic/Opportunity/Problem: Identified skin assessment has not completed on time. Current Measurement/Target: Will make sure all skin assessments will be completed weekly. Wound nurse will complete all assessments on weekly bases. Action/Interventions: The treatment nurse will evaluate and treat the wounds . Treatment nurse will do weekly assessments on every resident in building. Treatment nurse will document weekly on each resident .Target dates 09/30/21. Responsible: Treatment Nurse, LVN's, ADON's. In an interview on 07/21/22 at 1:33 PM, the DON stated she did not have a policy on pressure ulcer treatment. In an interview on 07/21/22 at 2:20 PM, the DON stated this week the floor nurses start doing their own wound care. The facility was in the process of training nurses on how to do the wound care before the survey started. The nurses are supposed to follow the physician orders to complete the wound care. The DON said Resident #20 had a really low BIMS score and was confused. She was the one checking everyone's wound care yesterday. The DON completed his wound care yesterday. She did not document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the TAR, that was her fault. She may not have got to all his wounds, she only looked at his butt. She did not perform treatment on his legs, heal or ankles. It was her mistake. She needed to look at his orders. She did not know he had those other wounds. It was important to make sure the wound care was completed daily because the wound could deteriorate. The wound care could be monitored for effectiveness for any needed changes. The nurses on the floor are aware they are supposed to be completing their own wound care. It was important for them to complete the weekly wound assessment to make sure the wounds are not deteriorating. The weekend supervisor LVN D completed the wound care on the weekend nurse. The wound treatment nurse was completing the wound care, so she was not sure if they had any previous training with the floor nurses on wound care. Record review of the facility training revealed the facility last trained nurses on Weekly Skin Assessment on 4/6/22. Record review of the facility's policy for Clean Dressing Change, not dated, revealed Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines .3. Each wound will be treated individually 13. Measure wound using disposable measuring guide 16. Secure dressing. [NAME] with initials and date. Record review of the facility's policy for Pressure Injury Surveillance, not dated, revealed Policy: A system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsening pressure injuries in the facility. Policy Explanation and Compliance Guidelines: 1. The treatment nurse or ADON serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. 2. RN's and LPN's participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician's and management staff, per protocol for notification of changes and in-house reporting of new or worsened pressure injuries. 3. The facility assessment will be used to prioritize surveillance efforts. In turn, surveillance data will provide information for subsequent monitoring FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medication carts ( 100 Hall Nursing Cart, 300 Hall Nursing Cart, and 400 Hall Nursing Cart) reviewed for drug labeling and storage. - The facility failed to ensure the 100 Hall Nursing Cart, 300 Hall Nursing Cart and the 400 Hall Nursing Cart did not contain multidose containers with no open dates. - LVN C failed to ensure the 300 Hall Nursing cart was secured/locked when not in use and unattended. These failures could place residents at risk of adverse medication reactions and drug diversions. Findings Included: 100 Hall Nursing Cart In an observation and interview on [DATE] at 9:55 AM, inventory of the 100 Hall Nursing Cart with LVN B revealed: - 1 10 mL open and in-use vial of Novolin R insulin at room temperature with no open date - 1 10 mL sealed vial of Lantus insulin at room temperature with no open date. LVN B said that when insulin vials or pens were removed from the refrigerator or punctured, nursing staff must label the container with the date it was opened. She said the open date was used to track the expiration date and since the insulin vials did not have an open date their expiration dates could not be establish so they could no longer be used because after the beyond use date insulin loses its efficacy and can become contaminated. LVN B said nursing staff were expected to check their medication carts as used for expired and inappropriately labeled medications such as insulin and once identified they must be discarded in the drug disposal bin located in the medication storage room. She said the use of expired insulin could place residents at risk of ineffective therapy and infection. 300 Hall Nursing Cart Observation on [DATE] at 12:06 PM revealed, Nurse Medication Cart in 300 Hall was observed unlocked in the hall in front of room [ROOM NUMBER].No staff was present at the 300 Hall Nurse Medication cart. There were no residents, staff, or visitors in the hall at this time. Observation and interview on [DATE] at 12:07PM revealed, LVN C walked out of room [ROOM NUMBER] and returned to the Nurse Medication Cart on 300 hall. She stated she left it quickly because she heard a resident calling out for assistance. LVN C stated the cart was to be locked any time you leave it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 because it was a safety risk. LVN C stated anyone could get into the medication cart and take something out. LVN stated she has been in serviced on the importance of securing the medication cart. Level of Harm - Minimal harm or potential for actual harm Inventory of the Nurse Medication Cart on 300 Hall on [DATE] at 12:07PM revealed: Residents Affected - Some - First drawer contained insulins, glucose monitoring supplies, syringes. - Second drawer contained tums, antiacid, vitamins, lidocaine 5% topical patch, individual resident medications. - Third drawer contained creams and ointments - Fourth drawer contained medication supplies In an interview on [DATE] at 8:34 AM, the DON stated all medication carts were to be locked when left unattended. There was no exception to the rule because there was a risk to anyone getting into the medication cart and taking something out, they should not have. The DON stated she looks at the carts when she walks around, and she had not seen any medication carts unlocked. The DON stated in the three months since she has been here, she has not done any in-services. The DON stated to prevent this from occurring again she will have a one-on-one in-service with the nurse involved on the importance of securing the medication carts and then she will in-service the rest of the facility staff to lock the medication carts when leaving them. In an interview on [DATE] at 01:32 PM with the Administrator, he stated it was absolutely very important for the medication carts to be locked when left unattended. He said it was a safety risk because any resident could get into the cart and take something. In an observation and interview on [DATE] at 9:40 AM, inventory of the 300 Hall Nursing Cart with LVN J revealed: - 1 open and in-use Lantus insulin pen room at temperature with no open date - 1 open and in use Levemir insulin pen at room temperature with no open date. - 2 open and in-use Trulicity pens, an injectable medication used to treat diabetes, at room temperature with no open date. LVN J said that nursing staff were expected to check their carts as used for inappropriately labeled medications. She said once a multi-dose insulin container was opened or taken from the refrigerator it should be labeled with the date in order to track the expiration date. LVN J said since the insulin containers did not have an open date, she could not determine their expiration date so they must be discarded in the drug disposal bin located in the medication storage room. She said once expired insulin loses its efficacy and can become contaminated and use of expired insulin would place residents at risk for insufficient therapy and infection. 400 Hall Nursing Cart In an observation and interview on [DATE] at 9:45 AM, inventory of the 400 Hall Nursing Cart with LVN A revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 - 1 open and in use Lantus insulin pen at room temperature with no open date. Level of Harm - Minimal harm or potential for actual harm - 1 open and in use Trulicity pen at room temperature with no open date. - 1 open and in-use Humalog insulin pen at room temperature with no open date. Residents Affected - Some LVN A said that nursing staff were expected to check their carts daily for expired and inappropriately labeled medications and the pharmacist audits the carts weekly. She said multi-dose insulin containers should be labeled with an open date once opened or taken out of the refrigerator in order to track their expiration date. She said once insulin expires it should not be used because the efficacy changes. LVN A said since the insulin pens didn't have an open date their expiration could not be determine so they must be discarded in the drug disposal bin located in the medication storage room. She said use of expired insulin places residents at risk of insufficient therapy. In an interview on [DATE] at 11:45 AM, the DON said all multidose insulin containers should be labeled with an open date when punctured or taken out of the fridge. She said the open date was used to track the expiration date because each manufacturer has a different beyond use date and after the manufacturer specified date the insulin loses efficacy/potency and there was a risk of contamination. She said if the expiration date cannot be determined the insulin must be discarded in the drug disposal bin located in the med room because use of expired insulin places residents at risk of adverse reactions. Record review of the facility policy titled Labeling of Medications and Biologicals with no revision date revealed, 8- labels for multi-use vials must include: a- the date the vial was initially opened or accessed (needle-punctured), b- all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that open vial, c- unopened or unassessed (needle-punctured) vials should be discarded according to the manufacturer's expiration date. Record review of the facility policy titled Medication Storage with no revision date revealed, 1, a- All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c- during medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage are/cart. 8- Unused medications: the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with out Destruction of Unused Drugs Policy. Record review of the facility policy titled Destruction of Unused Drugs with no revision date revealed, 2unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 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 of 5 staff members (CNA I and Business Office Staff H) reviewed for infection control Residents Affected - Few - CNA I and Business Office Staff H failed to wear appropriate PPE while on the floor. These failures could place residents at risk for the transmission of COVID-19. Findings included: An observation on 07/21/22 at 7:45 AM revealed, Business Office Staff H standing at the end of the 100 hall in front of the nursing station yelling down to LVN B who was more than 15 feet away as she prepared medication for administration to a resident. He pulled his mask below his chin as he called out to LVN B. An observation and interview on 07/21/22 at 8:14 AM revealed, CNA I standing in the 100 hall with her mask down below her chin talking to another staff member who was preparing medication for administration to a resident. CNA I said masks should be worn covering both the mouth and nose at all times while on the floor and it was not appropriate for her to pull down her mask when talking. She said that facility staff were required to wear masks to prevent the spread of COVID-19 and inappropriate mask wearing placed residents at risk of contracting COVID. In an interview on 07/21/22 at 11:45 AM, the Business Office Staff H said he removed his mask to talk to LVN B because he thought he would not have to yell as loud. He said that masks should be worn to cover both the mouth and nose at all times while on the floor and there was no exception. The Business Office Staff H said he should not have removed his mask because staff were required to wear masks to prevent the spread of COVID. He said that incorrectly worn masks places residents at risk of contracting COVID. In an interview on 07/21/22 at 12:27 PM, the DON said there was no specific facility policy/procedure on the proper way to wear PPE, but the facility used a CDC guidance document. She said that masks should be worn to cover both the mouth and nose at all times when staff were on the floor and there were no exceptions. The DON said that masks were worn in the facility to prevent the spread of COVID and by not wearing a mask correctly or at all residents are placed at risk for contracting COVID. Record review of the facility provided CDC document titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19) revised 06/03/20 revealed, REMEMBER: PPE must remain in place and be worn correctly for duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/facemask) during patient care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 9 of 9