Health inspection·October 12, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 properly secure medications in a locked compartment for 2 of 4 medication carts (800 Hall and 600 Hall) reviewed for drug storage. LVN A left 2 medication carts (800 Hall and 600 Hall) in the [NAME] Unit, unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings include: An observation on 10/10/2023 at 8:06 AM revealed a medication cart with the lock open, in the 600 Hall. A resident and a visitor were observed walking past the cart, toward the [NAME] nursing station. In an interview on 10/10/2023 at 8:10 AM, Restorative Aide B said she did not know who was responsible for the unlocked medication cart. She said it should be locked to ensure the medications were secured. An observation and interview on 10/10/2023 at 8:11 AM revealed LVN A walking toward the unlocked medication cart. She said the cart was hers and it should be locked. She said she was called away to another room and forgot to lock the cart. She said she was not sure how long she was away from the cart but knew it was not long. She said medication carts should always be locked when unattended to ensure residents do not get into the medications inside. An observation on 10/10/2023 at 8:15 AM revealed a second medication cart with the lock open. The cart was parked against the wall with the drawers facing into the hall, in the 800 Hall. No staff or residents were observed in the hall at the time. In a second interview on 10/10/2023 at 8:20 AM, LVN A stated she was responsible for the second medication cart as well. She said she had been administering medications on the 600 Hall and did not realize the cart on 800 Hall was left unlocked. She stated all medication carts should always be locked when unattended. In an interview on 10/11/2023 at 8:40 AM, LVN E stated she was a Unit Manager. She said LVN A was Page 1 of 7 676256 676256 10/12/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for two medication carts on 10/10/2023. She said she expected the carts to be locked when they were not attended to ensure the medications were secure and prevent residents from getting into medication not prescribed to them. She said she provided regular in-services and monitored staff by rounding regularly throughout the day. In an interview on 10/12/2023 at 1:11 PM, the Administrator and DON stated staff were trained on medication security and expected them to follow the facility's policy in ensuring medication carts were secured at all times. She said unlocked medication carts potentially allowed residents access to medication they were not prescribed to them causing adverse effects. The DON said she expected Unit Managers to monitor nursing staff on the halls, but she also rounded throughout the day as a resource for all nursing staff. Record review of facility in-services revealed Unit Manager, LVN E provided an in-service titled, Medication Storage, dated 4/10/2023. Record review of the facility's policy titled, Security of Medication Cart, revised April 2007 reflected, The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. 676256 Page 2 of 7 676256 10/12/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to ensure food items and clean dishes were kept away from airborne contaminants. 2. The facility failed to ensure food items were properly labeled and dated in accordance with professional standards. These failures could place all residents who received food from the kitchen, at risk for food contamination and food-borne illness. Findings include: An observation on 10/10/2023 at 8:25 AM revealed shelving under the steam table to have food crumbs, dust, and dried spills. Pots and pans were sitting on the shelf, face down, exposing the rim of the cookware to the contaminants on the shelf. A wire shelf near the dishwashing area and beside the cooking area had grease drips on the underside of the shelf where wire deep fryer baskets were stored. The shelfing was sticky and had a dust residue on them. Clean dishes, kitchen utensils, and plate covers were stored on the shelves. Three bins containing thickener, panko, and rice were observed in the food preparation area. The lids of the bins had food particles, spill marks, and a sticky residue on them. The dry storage room floor was observed with dirt, food crumbs, and a dried black substance on the floor, under shelfing, that resembled a food spill. Two ceiling air vents near the walk-in cooler and freezer had dust and brown fuzz clinging to the slats in the vent. An observation in the walk-in cooler revealed nine plated strawberry shortcake portions not labeled or dated. In an interview on 10/10/2023 at 8:30 AM, the Nutrition Services Director said the floors in the storage rooms should be cleaned daily however did not think they were cleaned since the past Thursday because that was the last time staff recorded it on the Cleaning Schedule. He said it did not look like they had been cleaned thoroughly. He said the floors should be clean to minimize the risk of bugs and food contamination. He stated the shelfing in the preparation area and cooking areas of the kitchen should be kept clean to ensure clean dishes did not have contact with anything that could contaminate food and cause food-borne illness to residents. He said all food items that were not in their existing sealed packaging needed to be dated and labeled to ensure freshness. He said he thought Dietary Aide C placed the strawberry shortcake in the walk-in but could not be sure. He said he planned on discarding them because they were not labeled or dated. He stated maintenance was responsible for cleaning the ceiling vents, but he had to log it in the Maintenance Logbook, kept at the nurse's station. He said he had not logged the vent cleaning request. He said he kept a cleaning schedule for staff to ensure they keep kitchen equipment clean and he was responsible to ensure cleaning tasks were completed. 676256 Page 3 of 7 676256 10/12/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 10/10/2023 at 10:40 AM, the Dietician stated she came to the facility weekly and did a monthly sanitation review with the Nutrition Services Director. She stated she last completed one about two weeks ago. She said she reviewed the observations made by the surveyor with the Nutrition Services Director. She said she agreed with all the surveyor's observations and discussed the need to ensure daily cleaning is followed up. She said food items not in their original packaging needed to be dated and leveled to ensure freshness. She said the kitchen needed to be kept clean to ensure food did not get contaminated and potentially place residents at risk of food-borne illness. In an interview on 10/12/2023 at 11:30 AM, the Maintenance Director stated he was responsible to clean kitchen vents but needed to be notified by the Nutrition Services Director. He stated he recently painted one vent near the dry storage area but was not made aware that the vents near the walk-in cooler or the freezer needed to be cleaned. He said he usually checked the Maintenance Logbook daily and signed off in the log when the tasks were completed. In an interview on 10/12/2023 at 11:30 AM, Dietary Aide C stated she did not leave the undated cake in the walk-in. She said she was not sure who did. She stated the kitchen staff were trained on dating and labeling all opened food items. She said the Nutrition Services Director recently had a staff meeting where this was discussed. She said the Nutrition Services Director followed up with the cleaning schedule. Record review of the facility's, Maintenance Logbook, from 09/01/2023 through 10/11/2023 reflected a kitchen vent needed painting and was completed on 10/5/23. On 10/11/2023 the Nutrition Services Director logged A/C vent needs paint. Record review of the kitchen, Cleaning Schedule, listed the storage room to be cleaned weekly. Initials were noted on Thursday. Shelving and food storage bins were not listed on the cleaning schedule. Record review of the facility's undated policy titled, General Sanitation of Kitchen, reflected, The staff shall maintain the sanitation of the kitchen through compliance with a cleaning schedule. Tasks will be assigned to be the responsibility of specific positions. Tasks will be addressed as to frequency of cleaning. A cleaning schedule will be posted and employees with initial and date tasks when completed. Record review of the facility's policy titled, Food Storage, revised 03/2019, reflected, .Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination.4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened. 11. Food is stored a minimum of 8 inches above the floor and 18 inches from the ceiling on clean racks or other clean surfaces, and is protected from splash, overhead pipes, or other contamination. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded. 15. Refrigeration: f. All foods should be stored to allow air circulation. Record review of the Federal Drug Administration Food Code, dated 2022, reflected,4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) 676256 Page 4 of 7 676256 10/12/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0812 Level of Harm - Minimal harm or potential for actual harm NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. Residents Affected - Some 676256 Page 5 of 7 676256 10/12/2023 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 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 (#138) of 3 residents reviewed for infection control. Residents Affected - Few CNA D failed to perform hand hygiene and put on the appropriate PPE, such as gloves and a gown, prior to entering and exiting Resident #138's room who was in insolation due to a diagnosis of clostridium difficile (infectious germ that can be transmitted from person to person). This failure caused potential for the spread of infection. Findings included: A record review of Resident #1381's face sheet dated 09/12/2023 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included Bacterial Infection (Illness or condition caused by bacterial growth or poisons (toxins). f), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), parkinsonism (nervous system disorder), hyperlipidemia (high level of lipids (fats) in the blood), and enterocolitis due to clostridium difficile (C-diff, infection of the large intestine). A record review of Resident #138's care plan dated 10/09/2023 revealed he required isolation for c-diff. PPE required to enter room, and signage placed on the door. A record review of Resident #138's entry MDS dated [DATE] provided no additional information. An observation on 10/11/2023 at 7:50 AM revealed CNA D in Resident #138's room with only a surgical face mask. CNA D used the bed control to raise the resident's bed. She was observed touching the resident's pillow, bed rail, bed side table, and arm as well. Signage on the door read, Contact precautions everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves before entry. Discard gloves before room exit. Put on gown before entry room, discard gown before exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A bin was observed outside the room containing gloves, gowns, face masks, and hand sanitizer. CNA D exited the room. In an interview on 10/11/2023 at 7:52 AM, CNA D said she was delivering Resident #138's breakfast tray and turned off his call light. She said she used the bed remote to raise the resident's bed so he could eat. She said she should have donned gloves, and a gown before entering the room because the resident was in isolation for c-diff, a contagious bacteria. She said she was trained in infection control processes but did not recall when she was last in-serviced. In an interview on 10/11/2023 at 8:40 AM, Unit Manager, LVN E stated that Resident #138 was on contact precaution isolation for c-diff and staff entering the room, for any reason, needed to don gloves, gown, and a face mask. She said staff should also doff PPE and wash their hands before leaving the room to minimize the risk of spreading infection to other residents in the facility. She said the facility expected staff use PPE every time they enter a room on contact isolation because touching 676256 Page 6 of 7 676256 10/12/2023 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0880 anything the infected resident touched could cause a spread of infection. Level of Harm - Minimal harm or potential for actual harm In an interview on 10/11/2023 at 8:50 AM, LVN F stated staff needed to don PPE every time they entered isolated rooms and doff PPE when they exited isolated rooms to limit the spread of infections. She said Resident #138 had c-diff and was on contact precautions. She said there was signage on the door of isolated rooms and staff knew they need to use PPE in these rooms. Residents Affected - Few In an interview on 10/11/2023 at 10:53 AM the DON / Infection Preventionist stated there was signage on the doors of all residents who were in isolation to direct staff and visitors to wear PPE prior to entering the rooms. She said Resident #138 was on contact isolation for c-diff, and she expected all staff to wear gloves, gown and face mask when entering the room for any reason. She said c-diff is contagious and not following isolation precautions could cause the spread of infection to other residents. She said even if staff do not touch the resident, touching anything the resident touched could cause the spread of infection. She said staff were trained on infection control practices and should know what is expected. She stated nursing management monitored infection control practices by rounding. Record review of facility in-services reflected an in-service titled Covid / infection control precautions, PPE, all staff must follow facility Infection control policy, dated 6/29/23. In-service titled, Handwashing / sanitizing, before and after donning and doffing gloves, Infection Control PPE designated PPE must be worn per company policy and manufacturer's guidelines, dated 2/17/23. Record review of the facility's policy titled, Contact Precautions, revised March 2019 reflected, Contact precautions are designed to reduce the risk of transmission of epidemiological importance microorganisms by direct or indirect contact. Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment. Room set up - sign on the door, Report to nurse before entering, with a stop sign, cart outside the room with gown, gloves, masks, and goggles. Gloves and hand washing, after removal of gloves, ensure hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments . 676256 Page 7 of 7