Health inspection·September 8, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure implementation of the written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 (RN D) of 16 staff reviewed for pre-employment suitability for hire, in that Residents Affected - Few The employment file did not include proof of the Employee Misconduct Registry [EMR] being checked prior to RN D working with residents. This deficient practice could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included: Record review of employment file for RN D revealed a start date of 3/06/2023; RN D did not have record of the EMR being checked prior to working with residents. Documentation indicated EMR check was completed on 9/06/2023. In an interview on 9/08/2023 at 1:15 PM, HR stated she could not find any other documentation of the EMR being checked prior to RN D providing care to the residents. HR stated she was sure the check was done as part of the hiring and on boarding process but the printout with the date was not saved. HR stated she would look to see if a policy existed for pre-employment checks and provide it if available. In an interview on 9/13/2023 at 9:44 AM, the CSM stated she was responsible for the background and EMR checks for the PRN staff. CSM stated RN D was initially hired as a PRN employee. The CSM stated she was having significant computer problems at the time in which documents were not saved electronically; the CSM stated the problem was so extensive the motherboard on her computer had to be replaced. The CSM stated she recalled performing the background check and saving it to her hard drive, but that there was no proof available. The CSM stated there is a new hire checklist that included the dates items were due for RN D. Record review of HHSC Employability Status Check Search Results for RN D, indicated database updated on 9/07/2023 at 5:24 AM. Record review of e-mail communication dated 9/12/2023 at 12:07 PM from the ADM, revealed screen shot of text messages to RN D from the CSM indicating screening, which included EMR, was complete on 3/03/2023. Record review of New Hire Check List for RN D documented background check started 2/24/2023 and Page 1 of 17 676228 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0607 completed 2/27/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident Rights and Dignity policy on Abuse Investigations, Prevention Programs and Reporting to Facility Management, revised 11/25/2017, revealed under the heading entitled Screening/Background Checks: 2. Criminal background checks will be completed on all applicants and current employees in accordance with federal and state laws. 4. The facility will not employ individuals who have been: a.) Found guilty of abusing, neglecting, or mistreating residents by a court of law; or b.) Have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and mistreatment of residents or misappropriation of their property. 5. The facility will report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other staff to the State Nurse Aide Registry or licensing authorities. Residents Affected - Few 676228 Page 2 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 4 (#16 and #3) residents in that: Residents Affected - Few 1. Resident #16 did not have oxygen use in his MDS assessment; and 2. Resident #3 had insulin use incorrectly coded in her MDS assessment. This could affect residents and result in discrepancies in treatments. The Findings were: 1.Record review of Resident #16's admission Record dated 9/07/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), neurocognitive disorder (are grouped into three subcategories: Delirium. Mild neurocognitive disorder - some decreased mental function, but able to stay independent and do daily tasks. Major neurocognitive disorder - decreased mental function and loss of ability to do daily tasks. Also called dementia.), obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep), and dyspnea (difficult or labored breathing). Record review of Resident #16's physician consolidated orders dated September 2023 revealed he had an order for Oxygen at 2-5 liters per minute per nasal canula or mask as needed for respiratory distress, and dyspnea. Record review of Resident #16's Quarterly MDS dated [DATE] revealed for section C Cognitive Patterns BIMS was 2/15 (severely impaired), section (initial order was 6/6/2023) O Special Treatment, Procedures, and Programs, Respiratory treatments C. Oxygen therapy was blank. K. Hospice care, marked with a x, meant yes. Record review of Resident #16's Care Plan dated 9/22/2023 revealed Resident #16 may require as needed oxygen therapy for signs and symptoms of wheezing and congestion. Record review of Resident #16's Care Plan dated 9/22/2023 revealed Resident #16 may require as needed oxygen therapy for signs and symptoms of wheezing and congestion. This was added after surveyor intervention. Observation on 9/06/2023 at 10:30 AM in Resident #16's room revealed he was laying down in bed and had the oxygen nasal cannula on his nasal area. Interview on 9/07/2023 at 3:16 PM with MDS nurse, stated he was responsible for MDS assessments. The MDS nurse stated he did not place oxygen on the MDS assessment for Resident #16 because it was an 676228 Page 3 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0641 as needed order. Level of Harm - Minimal harm or potential for actual harm Interview on 9/08/2023 at 4:02 PM with the Administrator stated the risk for not having and order for oxygen on MDS would be other staff might not know how to care for Resident #16 comfort measures while on hospice Residents Affected - Few 2. Record review of admission record dated 9/07/2023, revealed Resident #3 was a [AGE] year-old female originally admitted on [DATE]. Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #3's primary medical condition that best describes the primary reason for admission as debility [lack of strength or endurance], cardiorespiratory [relating to the action of both heart and lungs] conditions. Other active diagnoses included diabetes. BIMS summary score of 10, revealed Resident #3 was mildly cognitively impaired. Under section N, medications, Resident #3 was coded as received one injection (of any type) and one insulin injection in the last seven days prior to the assessment. Record review of the quarterly MDS assessment dated [DATE], under section N Medications, revealed Resident #3 was coded as received one injection (of any type) and one insulin injection in the seven days prior to the assessment. Record review of the quarterly MDS assessment dated [DATE], under section N Medications, revealed Resident #3 was coded as received one injection (of any type) and one insulin injection in the seven days prior to the assessment. Record review of the care plan revealed Resident #3 had a focus area of: diagnosis of diabetes; with the following associated interventions: diabetes medication as ordered by doctor, initiated 7/29/2021. Record review of the order summary report dated 9/07/2023, revealed Resident #3 had an active physician's order for: Ozempic: Inject 0.5 milligrams subcutaneously every day shift every Sunday for diabetes, with the start date of 8/06/2023. In an interview on 9/07/2023 at 7:40 AM, Resident #3 stated she was glad she was able to get on Ozempic. Resident #3 stated she received it weekly on Sundays, had no significant adverse or side effects, and thought it was helping her. Resident #3 stated she did not take insulin shots. In a group interview on 9/07/2023 at 3:35 PM, with the DON and ADON present, the MDS Nurse stated he was responsible for the MDS assessments. The MDS nurse stated the MDS assessment was coded incorrectly for Resident #3. The MDS nurse stated he coded Resident #3 as having received injections, but also coded the MDS assessment as if Resident #3 received insulin. The MDS nurse stated this was due to Resident #3 having a diagnosis of diabetes and receiving weekly Ozempic injections. The MDS nurse stated Ozempic was not insulin and should not be coded as such. In an interview on 9/07/2023 at 5:30 PM, the MDS nurse stated he could not find a policy associated with accuracy of clinical or assessment records. The MDS nurse stated he used the Resident Assessment Instrument requirements for MDS assessments. 676228 Page 4 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plans the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 (#16) residents in that: Resident #16 did not have a care plan for his oxygen use. This could affect all resident's and place them at risk of not having their needs addressed. o. The findings were: Record review of Resident #16's admission Record dated 9/07/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), neurocognitive disorder (are grouped into three subcategories: Delirium. Mild neurocognitive disorder some decreased mental function, but able to stay independent and do daily tasks. Major neurocognitive disorder - decreased mental function and loss of ability to do daily tasks. Also called dementia.), obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep), and dyspnea (difficult or labored breathing). Record review of Resident #16's physician consolidated orders dated September 2023 revealed he had an order for Oxygen at 2-5 liters per minute per nasal canula or mask as needed for respiratory distress, and dyspnea. Record review of Resident #16's Quarterly MDS assessment dated [DATE] revealed for section C Cognitive Patterns BIMS was 2/15 (severely impaired), section O Special Treatment, Procedures, and Programs, Respiratory treatments C. Oxygen therapy was blank. K. Hospice care, marked with a x, meant yes. Record review of Resident #16's Care Plan dated 9/22/2023 revealed Resident #16 may require as needed oxygen therapy for signs and symptoms of wheezing and congestion. This was added after surveyor intervention. In an observation on 9/06/2023 at 10:30 AM in Resident #16's room revealed he was laying down in bed and had the oxygen nasal cannula on his nasal area. In an interview on at 9/07/2023 at 3:16 PM with MDS nurse, stated he was responsible for MDS's, and the team was responsible for care plans . The MDS nurse stated he did not place oxygen on the Care Plan for Resident #16 because it was an as needed order. In an interview on 9/08/2023 at 4:02 PM with the Administrator stated the risk for not having an order for oxygen on MDS assessment would result in other staff not knowing how to care for Resident # 16 with comfort measures while on hospice services. 676228 Page 5 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0656 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676228 Page 6 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for 2 (Lead CNA K, and GNA C) of 5 nurse aid staff reviewed for competencies, in that; Residents Affected - Few The facility failed to provide an annual performance review and subsequent trainings based on the outcome of the review for Lead CNA K, and GNA C. This failure could place residents at risk of being cared for by untrained staff. Findings included: Record review of Lead CNA K's electronic training file revealed no evidence of a current annual performance review; the last annual performance review was dated 2/02/2022. Lead CNA K's rehire date was 8/16/2022. Record review of GNA C's electronic training file revealed no evidence of a current annual performance review. GNA C's hire date was 9/24/2018. In an interview on 9/08/2023 at 1:15 PM, HR stated she could not find any further evidence that GNA C had any additional trainings that included the annual competency or skills check off. HR stated she did not have a policy on required trainings. 676228 Page 7 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 (Residents #141 and #20) residents reviewed for pharmaceutical services, in that. 1. Resident #141's thyroid medications was late on 9/6/2023; and 2. Resident #20's medications were found in the bed and on the bedside table. This could affect residents with orders for medications and could result in residents not receiving the intended therapeutic effects of treatments resulting in diminished quality of health and well-being. The Findings were: 1. Record review of Resident #141's admission Record dated 9/06/2023 revealed she was admitted on [DATE] with diagnoses of hypothyroidism (abnormally low activity of the thyroid gland, resulting in slowing of growth and mental development in children and metabolic changes in adults). Record review of Resident #141's consolidated physician orders for September 2022 revealed order for Levothyroxine Sodium give 1 tablet by mouth in the morning for thyroid. Record review of Resident #141's Medication Administration Record dated 9/06/2023 revealed the Levothyroxine Sodium was scheduled for 6:00 AM and was administered on 7:25 AM by DON. Record review of Resident #141's admission MDS assessment dated [DATE] revealed section C Cognitive Patterns, BIMS was a 15/15 (cognitively intact), and section I Active diagnoses, Metabolic I3400 Thyroid disorder was x, meant yes. Interview on 9/07/2023 at 4:21 PM with Resident #141 stated her thyroid medication was late yesterday and another day she could not recall. Interview on 9/08/2023 at 4:00 PM with Administrator stated the medication error in general potential risk was it would go to next time period and possible overload for residents. Interview on 9/08/2023 at 4:15 PM with the DON confirmed Resident #141's thyroid medications late because the nurses were running behind and so she stepped in to help with medications administration.was it would go to next time period and possible over load for residents. 2. Record review of the admission record dated 9/06/2023, revealed Resident #20 was an [AGE] year-old male admitted [DATE]. Record review of Resident #20's quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 12, indicative of intact cognition. Resident #20's primary medical condition category that best describes the primary reason for admission was coded as debility [lack of strength or endurance], 676228 Page 8 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cardiorespiratory [relating to the action of both heart and lungs] conditions. Active diagnoses included heart failure, high blood pressure, kidney failure, and diabetes mellitus. Record review of Resident #20's care plan revealed the intervention, Administer medication(s) as ordered listed under the following focus areas: congestive heart failure, revised on 3/19/2023; high blood pressure, revised on 3/19/2023; potential fluid deficit, initiated 3/09/2023; and depression, initiated 6/22/2023. Record review of Resident #20's order summary report dated 9/06/2023, revealed the following scheduled oral medications: Aspirin 81 milligrams, one tablet by mouth in the morning related to heart failure with the start date of 8/01/2023; Atorvastatin 20 milligrams one tablet by mouth at bedtime related to high cholesterol with a start date of 8/01/2023; Flomax 0.4 milligrams one capsule by mouth at bedtime related to benign prostatic hyperplasia [non-cancerous growth of cells] with a start date of 8/01/2023; Flomax 0.4 milligrams one capsule by mouth in the morning related to benign prostatic hyperplasia with the start date of 8/01/2023; glipizide 10 milligram one tablet by mouth at bedtime related to diabetes with a start date of 8/01/2023; glipizide 10 milligram one tablet by mouth in the morning related to diabetes with a start date of 8/01/2023; iron 325 milligrams one tablet by mouth in the morning for supplement with a start date of 8/01/2023; Januvia 100 milligrams by mouth in the morning related to diabetes with the start date of 8/02/2023; Lasix 40 milligram one tablet by mouth at bedtime related to heart failure with the start date of 8/01/2023; Lasix 40 milligram one tablet by mouth in the morning related to heart failure with the start date of 8/01/2023; lisinopril-hydrochlorothiazide 20-25 milligrams one tablet by mouth in the morning related to high blood pressure with a start date of 8/02/2023; metformin extended release 500 milligram one tablet by mouth in the morning related to diabetes with the start date of 8 /02/2023; pioglitazone 45 milligrams one tablet by mouth in the morning related to diabetes with the start date of 8/02/2023; vitamin B12 1000 micrograms two tablets by mouth in the morning for vitamin deficiency with a start date of 8/02/2023; vitamin D3 25 micrograms give one capsule by mouth in the morning for supplement with a start date of 8/02/2023; Zoloft 50 milligrams give one tablet by mouth at bedtime related to depression with the start date of 7/09/2023. Record review of medication administration audit report dated 9/06/2023 at 11:58 AM revealed Resident # 20 had the following oral medications administered on 9/06/2023 by LVN A: iron 325 milligrams, administered at 9:24 AM; aspirin 81 milligrams, administered at 9:24 AM; vitamin B12 1000 micrograms, administered at 9:26 AM; glipizide 10 milligrams, administered at 9:25 AM; vitamin D 25 micrograms, administered at 9:26 AM; Januvia 100 milligrams, administered at 9:25 AM; metformin extended release 500 milligrams, administered at 9:25 AM; pioglitazone 45 milligrams, administered at 9:26 AM; Lasix 40 milligrams, administered at 9:26 AM; lisinopril-hydrochlorothiazide 20-25 milligrams, administered at 9:27 AM. In an observation on 09/06/2023 between 10:54 AM and 11:30 AM, Resident #20 was observed to have a white scored pill with GLP 10 imprinted on it, laying on top of his flat sheet on his torso. In addition, there was a pale pink pill loose on the bedside table next to and empty clear plastic medication cup. In an interview on 9/06/2023 at 11:33 AM, Resident #20 stated the nurse had been in his room much earlier to give him his pills. Resident #20 stated he did not recognize what pills were found loose on his bedside table or on his bedsheet. Resident #20 stated his nurse had been by while ago to give him his pills and he thought he took them all. 676228 Page 9 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation and interview on 9/06/2023 at 11:35 AM, LVN A stated she had just run out of the room within the last 20 minutes or so due to hearing someone calling out for help nearby. LVN A stated another resident had fallen, and she left the room before seeing Resident #20 take all of his pills. Without donning gloves, LVN A picked up the pale pink pill, with her bare hands, from the bedside table, and the white scored pill from the bed sheet and placed them in the clear plastic medicine cup. LVN A then offered the two pills to Resident #20. LVN A stated she was not sure which medications the two pills were from his earlier medication administration. LVN A then threw the clear plastic medication cup in the resident's trash and exited the room. In an interview on 9/06/2023 at 2:03 PM, the DON stated she was made aware of pills being found at Resident #20's bedside by LVN A. The DON stated another resident had fallen at 11:30 AM, that required LVN A to exit Resident #20's room quickly to render aid to the other resident. The DON stated the policy is for nurses to ensure all medication is taken at the time of administration. The DON stated she would have in-services initiated as a reminder to staff regarding this expectation. The DON stated she would provide a medication administration policy. The DON did not address concerns with administering pills found on the bedside or in bed linens or administering pills that had been touched with bare hands. The DON stated LVN A was distracted in an emergency and was flustered and nervous with state surveyors conducting observations. In a group interview on 9/8/2023 at 10:17 AM, with ADM present, the DON stated management was aware of issues with medication administration. The DON stated she had taken a firmer hand in providing training to staff regarding the importance of attention to detail and being attentive to the residents during medication administration and in general when interacting with residents. Record review Administering Medications policy, revised July 2008, revealed: 3. Medications must be administered in accordance with the orders, including any required time frame. 14. Staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc ) when these apply to the administration of medications. Record of In-Service Education Attendance Record dated 9/06/2023 with the start time of 2 PM on the topic of medication delivery revealed statement of, any delivery of medications to our residents are to stay with patient to ensure all medication is administered. If at any time medication is dropped on patient or floor, we are to use gloves and discard if on floor. Record review of PIP detail form dated 9/08/2023, entitled Medication Errors with a start date of 8/30/2023 and a target date of 11/08/2023, indicated the DON would provide educational in-services, observe medication passes, initiate weekly meetings starting 9/08/2023, and for the DON to perform ongoing medication audits. 676228 Page 10 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

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 all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 3 medication carts of 6 medication carts (Medication Cart A, Medication Cart B, and Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure Medication Cart A, Medication Cart B and Treatment Cart on the 100-wing were locked when left unattended in the common area of the 100-wing during breakfast. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 09/07/2023 at 7:45 AM, all three carts on the 100-wing were left unlocked and unattended while the nurses assisted residents in their rooms or at the communal dining area for breakfast. Medication Cart A and Medication Cart B, and Treatment Cart were not in direct line of sight of the nurse working in the communal dining area while she was preparing breakfast plates for residents. Medication Cart A and B contained over the counter and prescription medications; the Treatment Cart included over the counter and prescription medications associated with skin and wound care, along with necessary supplies such as dressings and tape. Ambulatory residents, residents with the ability to self-mobilize via wheelchair or rollator, along with other staff and visitors were observed in the immediate vicinity. In an interview on 9/07/2023 at 7:50 AM, LVN O stated Medication Cart A was her responsibility. LVN O stated she did not have access to Medication Cart B; however, the Treatment Cart access was via a code and responsibility for the Treatment Cart was shared among both nurses on duty. LVN O stated narcotics were not kept in the Treatment Cart. LVN O stated she was not aware she had left Medication Cart A or the Treatment Cart unlocked. LVN O stated while the other nurse was assisting residents in their rooms during breakfast it was her responsibility to monitor the floor and assist with breakfast in the communal dining area. In an interview on 9/07/2023 at 7:55 AM, LVN M stated he was responsible for Medication Cart B, and he shared responsibility with the other nurse, LVN O, for the Treatment Cart, this morning. LVN M stated he was not aware he had left Medication Cart B, or the Treatment Cart unlocked when he left the area. LVN M stated he felt a little overwhelmed as things were running a little behind this morning. LVN M stated he knew the carts needed to be locked for safety. In an interview on 9/07/2023 at 9:49 AM, the DON stated she expected the nurses to ensure the medication and treatment carts were locked when not in active use. The DON stated, this is nursing 101. The DON stated that requirement was included in new hire orientation, annual trainings, and PRN in servicing. The DON stated she would provide the appropriate policy. Record review of Storage of Medications policy revised April 2009, indicated in step 7. Compartments containing drugs and biologicals shall be kept locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 676228 Page 11 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

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, comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #20) of 34 residents, and 12 of 23 staff (PT F, OT H, ST G, RT I, OTA J, Lead CNA K, RN L, LVN M, LVN N, RN D, DON, and ADON) reviewed for infection control, in that; Residents Affected - Some 1. Medications were administered to Resident #20 that had been handled in an unsanitary manner. 2. Tuberculosis screenings were not completed in a timely manner for PT F, OT H, ST G, RT I, OTA J, Lead CNA K, RN L, LVN M, LVN N, RN D, DON, and ADON. This deficient practice could affect residents at the facility by exposing them to pathogens that could result in developing an illness that diminishes their quality of life. The findings included: 1. Record review of the admission record dated 9/06/2023, revealed Resident #20 was an [AGE] year-old male admitted [DATE]. Record review of Resident #20's quarterly MDS assessment dated [DATE], revealed a BIMS summary score of 12, indicative of intact cognition. Resident #20's primary medical condition category that best describes the primary reason for admission was coded as debility [lack of strength or endurance], cardiorespiratory [relating to the action of both heart and lungs] conditions. Active diagnoses included heart failure, high blood pressure, kidney failure, and diabetes mellitus. Record review of Resident #20's care plan revealed the intervention, Administer medication(s) as ordered listed under the following focus areas: congestive heart failure, revised on 3/19/2023; high blood pressure, revised on 3/19/2023; potential fluid deficit, initiated 3/09/2023; and depression, initiated 6/22/2023. Record review of Resident #20's order summary report dated 9/06/2023, revealed the following scheduled oral medications: Aspirin 81 milligrams, one tablet by mouth in the morning related to heart failure with the start date of 8/01/2023; Atorvastatin 20 milligrams one tablet by mouth at bedtime related to high cholesterol with a start date of 8/01/2023; Flomax 0.4 milligrams one capsule by mouth at bedtime related to benign prostatic hyperplasia [non-cancerous growth of cells] with a start date of 8/01/2023; Flomax 0.4 milligrams one capsule by mouth in the morning related to benign prostatic hyperplasia with the start date of 8/01/2023; glipizide 10 milligram one tablet by mouth at bedtime related to diabetes with a start date of 8/01/2023; glipizide 10 milligram one tablet by mouth in the morning related to diabetes with a start date of 8/01/2023; iron 325 milligrams one tablet by mouth in the morning for supplement with a start date of 8/01/2023; Januvia 100 milligrams by mouth in 676228 Page 12 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the morning related to diabetes with the start date of 8/02/2023; Lasix 40 milligram one tablet by mouth at bedtime related to heart failure with the start date of 8/01/2023; Lasix 40 milligram one tablet by mouth in the morning related to heart failure with the start date of 8/01/2023; lisinopril-hydrochlorothiazide 20-25 milligrams one tablet by mouth in the morning related to high blood pressure with a start date of 8/02/2023; metformin extended release 500 milligram one tablet by mouth in the morning related to diabetes with the start date of 8/02/2023; pioglitazone 45 milligrams one tablet by mouth in the morning related to diabetes with the start date of 8/02/2023; vitamin B12 1000 micrograms two tablets by mouth in the morning for vitamin deficiency with a start date of 8/02/2023; vitamin D3 25 micrograms give one capsule by mouth in the morning for supplement with a start date of 8/02/2023; Zoloft 50 milligrams give one tablet by mouth at bedtime related to depression with the start date of 7/09/2023. Record review of medication administration audit report dated 9/06/2023 at 11:58 AM revealed Resident #20 had the following oral medications administered on 9/06/2023 by LVN A: iron 325 milligrams, administered at 9:24 AM; aspirin 81 milligrams, administered at 9:24 AM; vitamin B12 1000 micrograms, administered at 9:26 AM; glipizide 10 milligrams, administered at 9:25 AM; vitamin D 25 micrograms, administered at 9:26 AM; Januvia 100 milligrams, administered at 9:25 AM; metformin extended release 500 milligrams, administered at 9:25 AM; pioglitazone 45 milligrams, administered at 9:26 AM; Lasix 40 milligrams, administered at 9:26 AM; lisinopril-hydrochlorothiazide 20-25 milligrams, administered at 9:27 AM. In an observation on 09/06/2023 between 10:54 AM and 11:30 AM, Resident #20 was observed to have a white scored pill with GLP 10 imprinted on it, laying on top of his flat sheet on his torso. In addition, there was a pale pink pill loose on the bedside table next to an empty clear plastic medication cup. In an interview on 9/06/2023 at 11:33 AM, Resident #20 stated the nurse had been in his room much earlier that morning to give him his pills. Resident #20 stated he did not recognize what pills were found loose on his bedside table or on his bedsheet. Resident #20 stated his nurse had been by while ago to give him his pills and he thought he took them all. In an observation and interview on 9/06/2023 at 11:35 AM, LVN A stated she had just run out of the room within the last 20 minutes or so due to hearing someone calling out for help nearby. LVN A stated another resident had fallen, and she left the room before seeing Resident #20 take all of his pills. Without donning gloves, LVN A picked up the pale pink pill, with her bare hands, from the bedside table, and the white scored pill from the bed sheet and placed them in the clear plastic medicine cup. LVN A then offered the two pills to Resident #20. LVN A stated she was not sure which medications the two pills were from his earlier medication administration. LVN A then threw the clear plastic medication cup in the resident's trash and exited the room. In an interview on 9/06/2023 at 2:03 PM, the DON stated LVN A made her aware of pills being found at Resident #20's bedside earlier in the morning. The DON stated another resident had fallen at 11:30 AM, that required LVN A to exit Resident #20's room quickly to render aid to the other resident. The DON stated the policy is for nurses to ensure all medication is taken at the time of administration. The DON stated she would have in-services initiated as a reminder to staff regarding this expectation. The DON stated she would provide a medication administration policy. The DON did not address concerns with administering pills found on the bedside or in bed linens or administering pills that had been touched with bare hands. The DON stated LVN A was distracted in an emergency and was flustered and nervous with state surveyors conducting observations. 676228 Page 13 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Administering Medications policy, revised July 2008, revealed: 3. Medications must be administered in accordance with the orders, including any required time frame. 14. Staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc ) when these apply to the administration of medications. Record review of In-Service Education Attendance Record dated 9/06/2023 with the start time of 2:00 PM, on the topic of medication delivery revealed statement of, any delivery of medications to our residents are to stay with patient to ensure all medication is administered. If at any time medication is dropped on patient or floor, we are to use gloves and discard if on floor. 2. Record review of employment file for PT F revealed a start date of 4/03/2023; PT F did not have record of TB screening prior to working with residents. Record review of employment file for OT H revealed a start date of 10/17/2022; OT H did not have record of TB screening prior to working with residents. Record review of employment file for RT I revealed a start date of 6/02/2003; RT I did not have record of a current TB screening, last TB screening documented as 2/02/2022. Record review of employment file for OTA J revealed a start date of 7/10/2017; OTA J did not have record of current TB screening, last TB screening documented as 7/01/2018. Record review of employment file for Lead CNA K revealed a start date of 8/16/2022; Lead CNA K did not have record of current TB screening, last TB screening documented as 5/04/2019. Record review of employment file for RN L revealed a start date of 8/01/2016; RN L did not have record of TB screening prior to working with residents, last TB screening documented as 10/27/2021. Record review of employment file for LVN M revealed a start date of 2/13/2023; LVN M did not have record of TB screening prior to working with residents, last TB screening documented as 11/13/2020. Record review of employment file for LVN N revealed a start date of 12/23/2022; LVN N did not have record of current TB screening, last TB screening documented as 6/29/2021. Record review of employment file for RN D revealed a start date of 3/06/2023; RN D did not have record of current TB screening, last TB screening documented as 3/14/2021. Record review of an employment file for DON revealed a start date of 3/20/2023; DON did not have record of TB screening prior to working with residents, last TB screening documented as 6/11/2023. Record review of an employment file for ADON revealed a start date of 1/23/2023; ADON did not have record of TB screening prior to working with residents, last TB screening documented as 6/11/2023. In an interview on 9/8/2023 at 1:15 PM, HR stated she could not find any other documentation of TB screenings for staff. HR stated PT F was employed at the facility from 4/03/2023, and her last day was 9/02/2023. HR stated she did not know why so many of the staff TB screenings were either missing or more than a year old. HR stated there was not a policy on TB screenings for staff. HR stated TB 676228 Page 14 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some screening was addressed in the Employee Handbook. HR stated she would provide a copy of that information. In an interview on 9/06/2023 at 2:15 PM, the DON stated when she started at the facility back in early March 2023, she felt that there was some chaos in record keeping of employee files. As the DON she administered and then kept copies of staff TB screenings. The DON stated, when she first started, she made a concerted effort to search the DON office and all available filing for any copies from the previous leadership but could not find any additional documentations. The DON stated she would forward all the available TB screenings she kept. The DON stated she believed copies of those TB screenings she had should be in the employees file by now. Record review of an undated page 12 from the Employee Handbook revealed, under the heading Health Requirements, All employees are required to receive an annual tuberculosis (TB) screen. Normally this will be performed at New Employee Orientation and annually thereafter. 676228 Page 15 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interview and record review, the facility failed to ensure that all staff had the appropriate competencies and skills sets to provide care and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 of 23 staff reviewed for competencies, in that; SW E, PT F, and ST G did not have mandatory training that outlined and informed staff of the elements and goals of the facility's quality assurance and performance improvement program. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately trained staff and could result in a decline in health and well-being. The findings included: Record review of SW E's electronic training file revealed no evidence of QAPI topics within the previous 12 months. Record review of PT F's electronic training file revealed no evidence of QAPI topics within the previous 12 months. Record review of ST G's electronic training file revealed no evidence of QAPI topics within the previous 12 months. In an interview on 9/08/2023 at 1:15 PM, HR stated HR stated she thought the ADM had all the required courses. HR stated PT F's last day was 9/02/2023. HR stated she did not have any further documentation to prove training and competencies. HR stated she did not have a policy on required trainings. 676228 Page 16 of 17 676228 09/08/2023 Kendall House Wellness & Rehabilitation 1050 Grand Blvd. Boerne, TX 78006

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to ensure that all staff had the appropriate competencies and skills sets to provide care and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 23 staff reviewed for competencies, in that; CNA and the ADM did not have the mandatory training that included the written standards, policies and procedures for the infection control program. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately trained staff and could result in a decline in health and well-being. The findings included: Record review of CNA B's electronic training file revealed no evidence of infection control topics within the previous 12 months. Record review of ADMs electronic training file revealed no evidence of infection control within the previous 12 months. In an interview on 9/08/2023 at 1:15 PM, HR stated CNA B had only been in her new role as CNA since 2/28/2023 which may be why all of her trainings were not completed as of yet; HR stated CNA B had been employed by the facility starting 5/25/2021. HR stated she thought the ADM had an many infection control courses. HR stated she did not have any additional documentation related to mandatory trainings. HR stated she did not have a policy on required trainings. 676228 Page 17 of 17