Health inspection·March 23, 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 a right to personal privacy and confidentiality of medical records for 1 (Resident #23) of 4 residents reviewed for privacy and confidentiality. Residents Affected - Few The facility failed to ensure LVN D logged out of his computer and protected Resident#23's Medication Administration Record. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #23's Comprehensive MDS assessment, dated 01/20/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (problem in the brain. It is caused by a chemical imbalance in the blood), quadriplegia (paralysis of all four limbs), and tracheostomy (an incision in the windpipe made to support breathing). During an observation on 03/22/2023 at 12:30 PM, LVN D stepped away from the medication cart, he entered Resident #23's room to administer medication through the G-tube (a surgically placed device used to give direct access to the stomach). LVN D left the computer screen (on top of the medication cart) unlocked where the medication administration record of Resident#23 was clearly displayed. The maintenance supervisor with the HHSC LSC surveyor passed by the medication cart. Also, a housekeeper observed in the hallway close by the medication cart. During an interview on 03/22/2023 at 12:45 PM, LVN D said he forgot to lock his computer screen before he stepped away from it. LVN D reported he had received training regarding resident rights to privacy and confidentiality of records, he stated he was supposed to provide privacy for all residents, as the failure could cause embarrassment for the resident. In an interview on 03/23/2023 at 1:08 PM, the DON stated all employees were expected to provide full visual privacy and confidentiality of information for all residents. The DON stated the failure to not protect the resident information would cause poor self-esteem for the resident. DON stated she was responsible to do routine rounds for monitoring. Record review of the facility's policy titled Resident Rights revised August 2020 revealed Purpose: To promote and protect the rights of all residents at the facility . Procedure . E. Privacy and Page 1 of 6 676270 676270 03/23/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

F 0583 confidentiality including the right to privacy in his/her specific oral, written, and electronic communication . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676270 Page 2 of 6 676270 03/23/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

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 3 (Resident #38, Resident #55, Resident #67) of 8 residents reviewed for ADLs. Residents Affected - Some The facility failed to ensure: 1- Resident #38 had his fingernails trimmed and cleaned. 2- Resident #55 had his fingernails trimmed and cleaned. 3- Resident #67 had her fingernails cleaned This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #38's Comprehensive MDS assessment dated [DATE] reflected Resident #38 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), contracture muscle of the left hand, muscle weakness, and elevated blood pressure. Resident #38 had a BIMS of 99 which indicated Resident #38 was unable to complete the interview. He required extensive assistance of two-persons physical assistance with bed mobility, toilet use, and personal hygiene. Review of Resident #38's Comprehensive Care Plan, revised 02/06/23, reflected the following: Focus: Resident has an ADL self-care performance deficit r/t CVA with hemiplegia ( cerebral infarction with paralysis). Goal: Resident will maintain current level of function in ADLs through the review date. Interventions: The resident requires total assistance with personal hygiene care. An observation on 03/21/23 at 10:22 AM revealed Resident #38 was lying in his bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan, the underside had dark brown colored residue, and the bed of the nails had dark brown colored residue. Resident #38 was nonverbal. 2- Review of Resident #55's Quarterly MDS assessment, dated 02/14/2023, reflected Resident #55 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included pain in joints of right and left hands, lack of coordination and type 2 diabetes mellitus. Resident #55 had a BIMS of 99 which indicated Resident #55 was unable to complete the interview. Resident#55 required extensive assistance of two-persons physical assistance with bed mobility, transfers, and personal hygiene. Review of Resident #55's Comprehensive Care Plan revised 02/27/23 reflected the following: Focus: resident#55 has an ADL self-care performance deficit r/t multiple fractures, non-weight bearing status. Goal: the resident will maintain current level of function in through the review date. Interventions: dressing / grooming - extensive assist. Observation on 03/21/23 at 10:57 AM revealed Resident #55 was laying in his bed. The nails on both 676270 Page 3 of 6 676270 03/23/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hands were approximately 0.3cm in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #55 was unable to answer questions. 3- Review of Resident #67's Comprehensive MDS assessment, dated 02/08/2023, reflected Resident #67 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, depression, muscle weakness, and lack of coordination. Resident #67 had a BIMS of 10 which indicated Resident #67 was cognitively moderately altered. Resident#67 required extensive assistance of two-persons physical assistance with bed mobility, transfers, and personal hygiene. Review of Resident #67's Comprehensive Care Plan revised 02/26/23 reflected the following: Focus: resident#67 has an ADL self-care performance deficit r/t debility. Goal: Resident #67 will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Interventions: the resident requires staff participation with personal hygiene and oral care. Observation on 03/21/23 at 11:05 AM revealed Resident #67 was laying in his bed. The nails on both hands were approximately 0.7cm in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #67 stated that she liked her nails long because she used them to scratch her skin. Resident #67 stated she did not like her fingernails dirty because it is disgusting. Interview on 03/21/23 at 11:38 AM, CNA A stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA A stated she would clean and trim Resident #38's nails right then. Interview on 03/21/23 at 11:53 AM, CNA B stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA B stated she would check with the nurse, if both residents, Resident #55, and Resident #67 not diabetic, she would clean and trim their nails. Interview on 03/21/23 at 11:59 AM, LVN C stated CNAs were responsible to clean and trim residents' nails during the showers. LVN C stated only nurses cut residents' nails if they were diabetic. LVN C stated no one notified her Resident #55 and Resident #67's nails were long and dirty, and she had not noticed the nails herself. LVN C stated Resident#55 and Resident#67 were diabetic she would clean and trim their nails. Interview on 03/23/23 1:08 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. DON stated she was responsible to do routine rounds for monitoring. Record review of the facility's policy titled Grooming Care of the Fingernails and Toenails, not dated, reflected Purpose: Nail care is given to clean and keep the nails trimmed. Policy: Fingernails are timed by Certified Nursing Assistants except for residents with the following conditions: A. diabetes or circulatory impairment of the hands . 676270 Page 4 of 6 676270 03/23/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

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 assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (nurses medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure: The medication supplies were secured or attended by authorized staff when the nurses' cart in hall 400 was left unlocked and unattended in the hallway 400. This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication. The findings include: During an observation on 03/22/2023 at 12:30 PM, LVN D stepped away from the medication cart, he entered Resident #23 room to administer medication through the G-tube (a surgically placed device used to give direct access to the stomach). LVN D left the nurses medication cart in hallway 500, by room [ROOM NUMBER], unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications accessible. The following medications were in the cart: Lamotrigine 25 mg, amlodipine 10 mg, carvedilol 25 mg, clonidine Hcl 0.1mg, and other medication. The maintenance supervisor with the HHSC LSC surveyor passed by the medication cart. Also, a housekeeper observed in the hallway close by the medication cart during the observation. Interview on 03/22/23 at 12:45 PM, LVN D stated he did not normally leave the cart unlocked. LVN D stated he was taught medication carts should be locked when not in use or out of sight because a resident could take the medications. LVN D stated he forgot to lock the medication cart. Interview on 03/23/23 at 1:08 PM, the DON stated it was her expectation that medication carts were locked when not in use. The DON stated if they were not locked, residents and staff could get into the cart and there would be opportunities for harm and medication to go missing. The DON stated she was responsible to do routine rounds for monitoring. Record review of facility's policy titled Storage of Medications dated August 2020, reflected the following: . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access 676270 Page 5 of 6 676270 03/23/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one of one meals (03/22/23 lunch) reviewed for dietary services. Residents Affected - Some The facility failed to ensure residents on regular diet received beans that were not burnt and overcooked for lunch on 03/22/23. This deficient practice placed residents at risk for poor food intake and nutrition. Findings included: Interview on 03/21/22 at 10:45 AM with Resident #41 revealed the food at times was overcooked and was burnt often. Interview on 03/21/23 at 11:13 AM with Resident #29 revealed the food was of poor quality, terrible taste and food was overcooked especially the vegetables. Observation on 03/22/23 at 12:56 PM of Lunch test tray of regular diet revealed charro beans tasted burnt and bitter taste. Observation and Interview on 03/22/23 at 1:03 PM with Dietary Manager revealed she tasted the charro beans and told surveyor they tasted burnt. She stated if she knew the charro beans were burnt she would not have served the beans to the residents burnt. She stated there were black pieces in the beans showing they were burnt. She stated usually vegetables were not overcooked or burnt. She stated she expected food not to taste burnt or be overcooked. Confidential Group Interview with 8 residents on 03/22/23 at 1:30 PM revealed all eight residents stated the food served at the facility was often burned and the beans at lunch today were burnt. One of the eight residents stated she told facility staff about food being burned and nothing was done because they still get burnt food. Review of Resident #5's grievance dated 11/03/22 reflected a grievance that included about her vegetables were overcooked. Dietary Manager in-serviced staff to ensure meals are cooked per recipe so they are not under or over cooked. Review of facility's menu for 03/22/23 reflected charro beans for lunch. The facility did not have a policy about food per Administrator on 03/23/23 at 12:50 PM. 676270 Page 6 of 6