Health inspection·August 21, 2023

F 0583 Keep residents' personal and medical records private and confidential. 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 residents had the right to personal privacy and confidentiality of his or her personal and medical records for 4 of 5 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for confidentiality of records. Residents Affected - Some The facility failed to protect the private healthcare information of Residents #1, #2, #3 and #4. This failure could place residents at risk for loss of privacy and dignity. Findings include: 1. Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Anemia (condition in which the blood doesn't have enough healthy red blood cells which leads to reduced oxygen flow to the body's organs), Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone) and Chronic Kidney Disease (long standing disease of the kidneys leading to renal failure. As the kidneys filter waste and excess fluid from the blood, waste builds up). 2. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Pressure Ulcer of right heel Stage 3 (wound caused by pressure on the skin with full thickness skin loss potentially extending into the fat layer), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Observation on 08/21/2023 at 10:47 AM revealed a Covid-19 test report for Resident #1 was left on top of the nurse's treatment cart and the computer screen was left open to the hallway with the personal information exposed for Resident #2 while LVN A was in Resident #2's room performing wound care. 3. Record review of Resident #3's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Atherosclerotic Heart Disease of native coronary artery (damage or disease in the heart's major blood vessels limiting blood flow to the heart) with unspecified Angina Pectoris (condition marked by severe pain in the chest caused by an inadequate blood supply to the heart), Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), unspecified abnormalities of gait and mobility, difficulty in walking, and need for personal assistance. Page 1 of 7 676227 676227 08/21/2023 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 08/21/2023 at 11:00 AM revealed the computer screen on top of the nurse's treatment cart was left open with personal healthcare information exposed for Resident #3. The cart was left unattended and facing the hallway as LVN A was in the resident's room. 4. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included Cervical Disc Disorder with Myelopathy (a compression of the spinal cord at the neck level of the spinal column resulting in sustained muscle spasms, increased or overactive reflexes, digit/hand clumsiness and or gait disturbance), and Fusion of Spine cervical region (surgery with bone grafts or metal implanted between the spinal bones to support them). Observation on 08/21/2023 at 11:20 AM revealed the computer screen on top of the nurse's treatment cart was left open with personal healthcare information exposed revealing wound are orders and the residents name for Resident #4. The cart was left unattended and facing the hallway while LVN A was in the resident's room. Interview on 08/21/2023 at 11:32 AM, LVN B stated it was a HIPAA violation to leave the computer screen open with a residents' information exposed. Interview on 08/21/2023 at 11:40 AM, LVN A stated by her leaving the computer screen open people could have seen a resident's personal information and it was a HIPAA violation. She stated she should have closed her computer screen before leaving the cart. Interview on 08/21/2023 at 4:30 PM the Director of Clinical Services stated it was a HIPAA violation to leave residents private medical information where it could be accessed by other people and the computer screens should be locked before the nurse leaves the cart. Record review of the facility policy and procedure titled Confidentiality of Personal and Medical Records, dated 01/01/2023, reflected Policy: This facility honors the residents right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage of location of the record. Policy explanation and Compliance Guidelines: 1. Personal and medical records include all types of records the facility might keep on a resident whether they are medical, social, fund accounts, automated or other. 2. Keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or individual surrogate or representative. 676227 Page 2 of 7 676227 08/21/2023 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

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. Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 1 nurse wound treatment carts reviewed for medication storage. 1. The facility failed to ensure the treatment cart was locked while unattended by LVN A. 2. The facility failed to ensure a medication was not left unattended on top of the nurse wound treatment cart. These failures could place residents at risk of injury and misuse of medication. Findings include: Observation on 08/21/2023 at 10:47 AM of the nurse wound treatment cart revealed it was unlocked and unattended outside of Resident #2's room. Observation on 08/21/2023 at 11:00 AM of the nurse wound treatment cart revealed it was unlocked and unattended outside of Resident #3's room. Observation on 08/21/2023 at 11:20 AM of the nurse wound treatment cart revealed it was unlocked and unattended outside of Resident #4's room while the nurse was in the room. There was a bottle of wound cleanser left on top of the cart. The label stated Warnings: Keep out of reach of children. For external use only. Do not use in the eyes. If swallowed, get medical help, or contact a Poison Control Center immediately. Interview on 08/21/2023 at 1:19 PM, LVN A stated by leaving the medication cart unlocked residents could get into the cart and access items they were not supposed to have. She stated by her leaving the wound cleanser on top of the cart and unattended, someone could spray it into their eyes or put it in their mouth and drink it. She stated she should not have left the cart unlocked and the wound cleanser should have been locked up in the cart. Interview on 08/21/2023 at 4:30 PM, the Director of Clinical Services stated the treatment cart should be locked when unattended. He further stated the hazard of leaving a wound care cleanser on the treatment cart was a confused resident could drink it, spray it in their eyes and could potentially make them ill. Record review of the facility policy and procedure titled Medication Storage, dated 01/01/2023, reflected General guidelines: All drugs and biologicals will be stored in locked compartments. (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 676227 Page 3 of 7 676227 08/21/2023 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3 and #4) reviewed for infection control. Residents Affected - Some The facility failed to ensure LVN A performed wound care for Resident's #2, #3, and #4 in a manner to decrease potential for infection and/or cross contamination. These failures could put residents at risk for infections. Findings include: 1. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Pressure Ulcer of right heel Stage 3 (wound caused by pressure on the skin with full thickness skin loss potentially extending into the fat layer), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of the Order Summary Report dated 08/19/2023, for Resident #2 reflected right heel, cleanse with wound cleanser, pat dry. Apply Santyl ointment, and cover with border gauze. Observation on 08/21/2023 at 10:47 AM revealed LVN A performed wound care for Resident #2's right heel pressure ulcer by wiping with 2 X 2 gauze across the wound from dirty to clean areas. 2. Record review of Resident #3's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Atherosclerotic Heart Disease of native coronary artery (damage or disease in the heart's major blood vessels limiting blood flow to the heart) with unspecified Angina Pectoris (condition marked by severe pain in the chest caused by an inadequate blood supply to the heart), Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), unspecified abnormalities of gait and mobility, difficulty in walking, and need for personal assistance. Observation on 08/21/2023 at 11:00 AM of wound care for a pressure ulcer to Resident #3's left buttock revealed LVN A did not sanitize her hands after picking up a book that had fallen off her cart. She then proceeded to touch several 2 X 2 gauze with her unsanitized hands and placed it on a clean wax paper surface. She cut off a piece of collagen and then touched the collagen with her unclean hands. She then placed the remainder of the contaminated collagen back in the package. LVN A sanitized her hands and put on gloves. She touched her face with the gloves and then performed wound care for Resident #3's left buttock pressure ulcer by wiping with 2 X 2 gauze across the wound from dirty to clean areas. LVN A then kept her contaminated gloves on and opened the door to the resident's room. 3. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included Cervical Disc Disorder with Myelopathy (a compression of the spinal cord at the neck level of the spinal column resulting in sustained muscle spasms, increased or overactive reflexes, digit/hand 676227 Page 4 of 7 676227 08/21/2023 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

F 0880 Level of Harm - Minimal harm or potential for actual harm clumsiness and or gait disturbance), and Fusion of Spine cervical region (surgery with bone grafts or metal implanted between the spinal bones to support them). Record review of an Order Summary dated 08/18/2023 for Resident #4 reflected left heel, cleanse area with wound cleanser and pat dry. Apply collagen dressing and cover with border gauze one time a day. Residents Affected - Some Record review of the MDS, quarterly dated 07/4/2023, for Resident #4 reflected a BIMS score of 15, which indicated intact cognitive status. Section M - Skin Conditions did not reflect a pressure ulcer but stated she was at risk of developing pressure ulcers/injuries. Record review of a Care Plan for Resident #4, dated 05/12/2022 and revised on 08/07/2023, reflected she had Unstageable to bilateral heels. Goal: Wounds will decrease in size through next review date. Interventions/Tasks: Follow facility protocols for treatment of injury. Wound care physician on consult for care. Observation on 08/21/2023 at 11:07 AM of wound care for a pressure ulcer to Resident #4's left heel revealed LVN A opened the top drawer to the treatment cart, then opened the 2nd drawer and picked up some 2 X 2 gauze with unclean hands and placed it on clean wax paper. LVN A used uncleaned scissors to cut a piece of collagen which she dropped onto the computer keys, picked up and placed on the clean surface with other wound care supplies. LVN A removed the dirty dressing from Resident #4's heel, and using the same gloves cleaned across the wound from dirty to clean areas using the contaminated 2 X 2 gauze. She then placed the contaminated collagen on the wound. Interview on 08/21/2023 at 11:40 AM, LVN A stated she was trained regarding wound care on another job by watching other nurses do treatments. She stated she had not received wound care training. She stated infection control was very important, but she did not follow all guidelines as closely as she should. She stated the wound care scissors should have been cleaned after each use and put on a clean surface so they would not pick up bacteria. She stated by touching the 2 X 2 gauze with her unclean hands, she contaminated them. She further stated she should always wash her hands before putting on her gloves and then perform wound care as the wounds could get infected. Interview on 08/21/2023 at 1:09 PM, LVN A stated by wiping the gauze across a wound from a dirty to a clean area, it could pull bacteria into the wound. Interview on 08/21/2023 at 4:30 PM, the Director of Clinical Services stated the nurse should wash their hands prior to doing a treatment and in between a dirty to clean procedure. He further stated by not following proper hand hygiene during wound care the potential was there for the resident to get an infection. He stated he did not know if LVN A had received wound care training. Record review of the facility policy and procedure titled Clean Dressing Change, dated 01/01/2023, reflected Policy: It is the policy of this facility to provide wound are in a manner to decrease potential or infection and/or cross contamination. Policy Explanation and Compliance Guidelines . 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and 676227 Page 5 of 7 676227 08/21/2023 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

F 0880 other body sites. Level of Harm - Minimal harm or potential for actual harm 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into Appropriate receptacle. Residents Affected - Some 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound) Pat dry with gauze. 13. Measure wound using disposable measuring tape. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. 16. Secure dressing. [NAME] with initials and date. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Record review of the facility policy and procedure titled Hand Hygiene, dated 01/01/2023, reflected Policy: All staff will perform propre hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility policy and procedure titled Infection Prevention and Control Program, dated 06/01/2023, reflected Policy: This facility has established and maintains an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Equipment Protocol: a. 676227 Page 6 of 7 676227 08/21/2023 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

F 0880 Level of Harm - Minimal harm or potential for actual harm All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Staff education: Residents Affected - Some All staff shall receive training, relevant to the specific roles and responsibilities, regarding 676227 Page 7 of 7