Health inspection·July 19, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #2) of 5 residents reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident#2 had their fingernail, and toenails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL (Activities of daily living) care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: A record review of Resident#2 face sheet dated 07/19/2023 reveled: Resident#2 was an [AGE] years old female admitted to the facility on [DATE] with the diagnoses of: need for assistance with personal care, hemiplegia affecting right dominant side, contracture right wrist, cognitive communication deficit, dementia(a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) . A record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was unable to answer the brief mental status questions. The review further reflected the resident was total dependent on staff for the ADL's (activity of daily living). A record review of Resident #2's Comprehensive Care Plan, dated 12/13/2020 to present, reflected Problem: (Resident #2) Self-care deficit - Extensive assistance required with ., hygiene, R/T DEMENTIA, IMPAIRED MOBILITY . (Resident#2) has a Behavior- Digging/ playing in bowl movement Goal: (Resident#2) will be easily redirected by staff for the next 90 days. Interventions: Keep (Resident#2) fingernails clean and trimmed. Redirect Resident when noted digging/ playing in bowel movement. Encourage Resident not to dig/ play in bowel Podiatrist to examine feet and trim nails. Schedule appointment every 3 months. Clean and manicure fingernails as needed. An observation on 07/19/23 at 11:15 am revealed Resident #2 was laying in her bed wearing a hospital gown. Her left-hand fingernails were short with brown matter underneath. Her right hand was severely contracted, the first, second and third fingernail were approximately 0.4 centimeter in length extending from the tip of her fingers, with dirty matter underneath the second, third, and forth fingernail. Interview on 07/19/2023 at 01:15 pm CNA-J stated the Resident#2's always digging back there Page 1 of 5 676256 676256 07/19/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (meaning her Buttocks area), and she cleaned underneath under net the resident fingernail when she noticed they are dirty, the podiatric podiatrist came and take care of the resident toenails. CNA-J stated Resident#3 refused care most of the time. Interview and observation on 07/19/2023 at 1:30 pm LVN O stated the Resident#2 resisted care. LVN O stated the nail care for the resident was done by the nurses and the CNAs when it was noticed, and the risk to resident was the development of an infection. Interview on 07/19/2023 at 3:00 p.m. the DON stated resident's fingernails care were done by CNAs, and nurses, and the facility social worker scheduled residents for podiatric care every 60 days (about 2 months). Interview on 07/19/2023 at 4:10 pm with the SW revealed: SW stated Resident#2's fingernails are monitored and done by the nurses, and it was hard to get to her right-hand fingernail related to the severe contracture in it, the resident family was made aware of it. 676256 Page 2 of 5 676256 07/19/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0687 Provide appropriate foot care. 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 to ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility and failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 (Resident #3) of 5 residents reviewed for foot care. Residents Affected - Few The facility failed to ensure Resident #3 had his toenails trimmed. This failure could place residents who were dependent on staff for foot care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: A record review of Resident#3 face sheet dated 07/19/2023 revealed: Resident#3 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of: type 2 diabetes mellitus, primary generalized arthritis (is the swelling and tenderness of one or more joints), muscle weakness, cognitive communication deficit. Review of Resident #3's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 2 indicating severe cognitive impairment. Review of Resident #3's Care Plan dated 12/13/2020 to present reflected the following: resident podiatric care was not care planed. An observation on 07/19/23 at 12:00 pm revealed Resident #3 setting up in the chair in his room, wearing day attire, bare feet with long pointy toenails approximately 0.4 centimeter in length extending from the tip of his toes. Interview and observation on 07/19/2023 at 1:30 pm LVN O stated that Resident #3 on the list for the podiatrist once a month. LVN O stated that Residnet #3 sometime refused foot care, and toe nail clipping. LVN O stated the nail care for the resident was done by the nurses and the CNAs when it was noticed, and the risk to resident was the development of an infection. Interview on 07/19/2023at 3:00 p.m. the DON stated resident's nails care were done by CNAs, and nurses, and the facility social worker scheduled residents for podiatric care every 60 days (about 2 months). Interview on 07/19/2023 at 4:10 pm with the SW revealed: Resident #3 podiatric care was scheduled every 60 days, and the Resident #3 refused every time. 676256 Page 3 of 5 676256 07/19/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (CNA J) staff observed for infection control. Residents Affected - Few CNA (Certified Nursing Assistance J failed to perform properly change gloves, and hand hygiene during incontinence care for Resident #1. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #1's face sheet, dated 07/19/2023, reflected she was a [AGE] year-old female admitted to facility 10/02/2020. Her diagnoses included muscle weakness, hypothyroidism (is a condition where there is not enough thyroid hormone in the blood stream and the metabolism slows down), osteomyelitis (is an inflammation or swelling of bone tissue that is usually the result of an infection), need for assistance with personal care, abnormalities of gait and mobility, pneumonia (is an infection that inflames the air sacs in one or both lungs). Review of Resident #1's most recent Quarterly MDS Assessment, dated 07/18/2023, reflected she had a BIMS score of 00 indicating sever cognition impairment. The review further reflected the resident always incontinent of bladder and bowel. Review of Resident #1's Care Plan dated 10/05/2020 to present reflected the following: Category[Resident #1] is incontinent of: Bladder and Bowel. Goal: Resident#1 will remain clean, dry and odor free and no occurrence of skin breakdown will occur over the next 90 days. Interventions: Monitor for s/s of skin breakdown-report to MD and RP. An observation on 07/19/2023 at 11:17 a.m., during incontinence care for Resident #1 in resident's room revealed CNA J (Certified Nursing assistant) washed her hands in the resident bathroom sink, and during the process of donning (put on) gloves, she dropped one glove on the floor, picked it up and wore it. CNA J got wipes, unfastened Resident #1 brief, tacked the brief between Resident#1 legs, cleaned Resident#1 front parts using the same handful of wipes folding them each time she moved from cleaning one site to the other. CNA J with the help of CNA F turned the Resident#1 to her right side. CNA J removed the urine-soaked brief put it in the trash, and got a clean wipe, cleaned Resident#1 buttocks area, got the clean brief put it under the Resident#1 without changing gloves, turned the Resident#1 back to her back, fastened the brief. CNA J removed gloves, disposed of them in the trash. CNA J sanitized her hands with a hand sanitizer from her uniform pocket. CNA J took the plastic bags with dirty linen, and trash to the soiled utilities room. In an interview on 07/19/2023 at 01:15 p.m., : CNA-J stated that she was supposed to get rid of the glove she picked up from the floor, sanitized her hands and got a clean glove. CNA J stated she changed glove between resident's care. CNA J stated during the incontinent care when going to resident room, she sanitized hands, put on clean glove. CNA J stated she cleaned the resident, removed the dirty brief, and put the clean brief on the resident, fastened it, covered the resident, and remove 676256 Page 4 of 5 676256 07/19/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the glove sanitize hands, and take the trash to soiled utility room. CNA hand sanitization prevents cross contamination during resident's care. CNA-J stated that she had in-service on hand hygiene, and resident incontinent care during orientation. In an interview on 07/19/2023 at 3:00 p.m. with DON that acts as IP (Infection preventionist) to. The DON stated the protocol for hands hygiene during resident's peri care was: the staff should wash hands before and after resident's peri care. When the DON was asked for clarification, she stated staff were supposed to perform hands hygiene before and after removing gloves. She stated staff were supposed to sanitize hands when moving from dirty to clean not to cross contaminate. The DON clarified further that the staff were supposed to remove the dirty brief when the clean one was under net underneath the resident, and when the staff remove the dirty brief, the clean brief was supposed to be under net underneath the resident, and no glove change required during this time. The DON was texting on her phone during this time of the interview, and received a phone call, and she stepped away from the table to answer the phone call. After the DON came back, she clarified the previous statement by stating during peri care the staff supposed to take the dirty brief, change glove, and perform hands hygiene and put the clean brief on the resident. The DON stated the risk to residents was they can receive an infection or skin broke down. The DON stated the IP s nurses do the spot check with the resident's direct care staff randomly to check if it's done according to facility policies. Record review of the facility policy titled Handwashing dated 2012 reveled: Hand washing is the single most important means of preventing the spread of infection. After Patient contact- Wash hands with soap and running water .- May use Hand sanitizing gel in place of soap and water 676256 Page 5 of 5