Health inspection·October 11, 2022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 3 of 4 medication carts reviewed for medication storage and security in that: The facility failed to ensure the medication carts on Hall 100, Hall 200 and Hall 300 were locked when unattended. This failure could place residents at risk of having access to unauthorized medications, risk for drug diversion or accidental ingestion. Findings included: Review of Resident #51's admission record dated 08/21/19 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus, Dementia with behavioral disturbance. Record review of Resident #51's MDS assessment, dated 08/29/22, indicated in part: BIMS = 09 indicating the resident had moderate cognitive impairment. Record review of Resident #51's care plan, dated 09/12/22, indicated in part: FOCUS: Short term memory problems. Decision poor and requires supervision and cueing. Impaired decision making. GOAL: Resident will effectively communicate simple needs to staff. INTERVENTIONS: Break down tasks of daily life into smaller steps, encourage verbalization, follow same routine daily, reorient as needed, speak, clearly slowly and face to face. Review of Resident #21's admission record, dated 01/21/22, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #21's MDS assessment dated [DATE] indicated in part: BIMS = 08 indicating the resident had moderate cognitive impairment. Record review of Resident #21's care plan dated 09/01/22 indicated in part: FOCUS: The resident has a behavior problem of stating suicidal thoughts. GOAL: The resident will have fewer episodes of behavior by review date. INTERVENTIONS: Intervene as necessary to protect the rights and safety of Page 1 of 7 676348 676348 10/11/2022 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some others, divert attention, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. An observation on 10/09/22 at 11:10 AM revealed an unattended unlocked medication cart on Hall 200. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. Resident # 51 was observed wheeling herself passed the unlocked medication cart to her room. No staff was in the vicinity of the unlocked medication cart. At 11:14 AM LVN A came by and locked the cart with surveyor's intervention. LVN A stated that she does not know where LVN B was at that time but the medication cart should be locked while unattended. An observation on 10/09/22 at 11:20 AM revealed an unattended unlocked medication cart on Hall 100. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. Resident #21 was observed sitting in his wheelchair hall, 5 feet away. No staff was observed in the vicinity of the unlocked medication cart. At 11:22 AM LVN C came by and locked the cart with surveyor's intervention. An observation on 10/09/22 at 11:25 PM revealed an unattended unlocked medication cart on Hall 300. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. No staff or residents were seen in the vicinity. LVN D walked by and locked the cart with surveyor intervention. LVN D stated that LVN A was passing medications from the medication cart, but she did not know where LVN A was at the time. An observation on 10/09/22 at 2:53 PM revealed an unattended unlocked medication cart on Hall 100. The cart contained multiple medicine bottles, over the counter medications and prescription blister packs that contained pills. No staff was observed in the vicinity of the unlocked medication cart. During an interview on 10/09/22 at 11:14 AM with LVN A stated that no the medication cart should not be unlocked while unattended. During an interview on 10/09/22 at 11:30 AM, LVN B stated that she was distracted to another hall where she had to go to another residents room and forgot to lock it. We keep meds in the medication carts and it could be dangerous to other residents. I have been here 5 years and I know it should be locked. During an interview on 10/09/22 at 11:30 AM, LVN C stated that she was in a resident's room administering medications and left the medication cart unlocked and unattended which can be dangerous because anyone could get into the medication cart and get medications that they should not have. During an interview on 10/11/22 at 12:00 PM, the DON stated that she was aware of the unlocked and unattended medication carts. She stated that she put out an in-service on 10/10/22 that read in part make sure that medication cart is locked and privacy screen is on every time you are not within arms reach of your medication cart. Review of the facility's policy, titled Medication Cart, Administration of Drugs, reflected (in part): I the cart is left at any time during medication pass due to an emergency, it must be locked. 676348 Page 2 of 7 676348 10/11/2022 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 service safety for 1 of 1 kitchen reviewed for dietary services in that: 1. The facility failed to label, date, and properly seal food items. 2. The facility failed to discard expired food items. 3. The facility failed to store dishes/utensils inverted. These deficient practices could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings included: Observation on 10/09/22 at 11:10 AM during a walk-through inspection of the kitchen revealed the following: plates in the dish rack were stored not inverted and not covered plate holders stored were not inverted and not covered Spice containers stored on the shelf above sink/prep table: 7 containers with lids left open while not in use 1 1-gallon pitcher with label which read tomato soup, prep date 10/02/22 and expiration date 10/5/22 in the walk-in refrigerator 1 1-gallon pitcher with label which read chicken noodle soup, prep date 10/1/22 and expiration date 10/4/22 in the walk-in refirgerator 1 1-gallon pitcher with label which read super cereal, prep date 10/4/22 and expiration date 10/7/22 in the walk-in refrigerator 676348 Page 3 of 7 676348 10/11/2022 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0812 - Level of Harm - Minimal harm or potential for actual harm 1 metal bowl with label which read Joyce's pasta, prep date 10/4/22 and expiration date 10/7/22 - Residents Affected - Some 7 2-gallon resealable plastic bags of various frozen foods with dates but no labels that indicated contents in the walk-in freezer 1 2-gallon resealable plastic bag of cereal with dates but no label that indicated contents in the dry storage room Observation on 10/10/22 at 9:50 AM during a walk-through inspection of the kitchen revealed the following: Plates in rack continued to be stored not inverted or covered. Plate holders not inverted or covered. Large plastic tub of clean bowls drying outside of dishwashing area not stacked and inverted, placed into tub to dry. Serving spoons and ladles hanging from rack not inverted. In an interview on 10/10/22 at 10:00 AM with Director of Food Services, she stated that during the last visit from the corporate dietary manager, she was told to store plates serving side up. She stated that she was not aware that serving utensil, scoop, ladles had to be stored inverted or in drawers. She stated that expired foods should not be in the refrigerator and that she was unsure why it had not been removed. She stated that the kitchen staff has been trained to label everything and she had no explanation for why there were bags of food in the freezer and dry storage that were not labeled. In an interview on 10/11/22 at 1:05 PM with the Administrator, he stated that his expectation for the kitchen was that everything should be in good working order. He stated that utensils and dishes should be stored in a sanitary/clean environment. He stated that expired foods should be discarded properly and never left in the kitchen. Review of facility policy titled Food Safety in Receiving and Storage dated 1/1/10, revealed, in part: 676348 Page 4 of 7 676348 10/11/2022 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0812 - Level of Harm - Minimal harm or potential for actual harm Food that is repackaged is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container/lid is labeled with the name of contents and dated with the date it was transferred to the container. Residents Affected - Some Review of FDA Food Code 2017 revealed the following: https://www.fda.gov/food/retail-food-protection/fda-food-code Food storage/labelling 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Packaged food (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Packaged food (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Packaged food and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Packaged food (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first prepared ingredient. Packaged food 92 (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 676348 Page 5 of 7 676348 10/11/2022 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 8 residents (Resident # 72) reviewed for resident call systems, in that: Residents Affected - Few The facility failed to ensure Resident #72's call button was functioning. This failure could have placed residents at risk of being unable to obtain assistance when needed. The findings were: Review of Resident #72's admission Record, dated 10/11/22, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] . He had diagnoses which included end stage renal disease with dependence on dialysis, need for assistance with personal care, diabetes, and history of strokes. Review of Resident #72's Quarterly MDS Assessment, dated 9/26/22, revealed: -He scored a 7 of 15 on his mental status exam (indicating severe cognitive impairment). -He needed extensive assistance of one or two staff for ADLs. -He had no range of motion impairments but needed a wheelchair. -He was on dialysis. Review of Resident #72's Care Plan, initiated 9/19/19, revealed a focus that resident required assistance with ADLs. The identified goal was Resident is able to perform self-care to optimal level and maintain strength and endurance. Interventions included: encourage independence in performance of self-care and mobility within limitations and provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs each shift. Review of Resident #72's Care Plan, revised 10/4/22, revealed a focus that: Resident has a history of falling. Identified interventions included: 10/24/19 Fall found on floor in room, no apparent injuries noted. Intervention: education on call light Observation and interview on 10/09/22 at 2:26 PM showed Resident #72 was in bed. He had no call light, and the call light cord was missing from the base of the call light plug. The part of the plug that would have the call light cord coming out of it faced Resident #72's roommate (opposite of Resident #72's bed). Resident #72 said when he needed help, he needed to wait until staff came and that could take a long time. Resident #72 stated he had not fallen but did have to wait for pain medications. Resident #72 was asked how he could call for help and replied, I don't, I wait. During an observation and interview on 10/09/22 at 02:31 PM, ADON F was shown Resident #72's call light. ADON F said, Oh my God, his call light broke completely. She pulled the call light plug out of the socket and the call light sounded. So ADON F plugged it back in and stated, that needs to be 676348 Page 6 of 7 676348 10/11/2022 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fixed. She stated the staff did rounds to prevent this from happening. She said the aides were the first round of defense, but Managers did checks during the work week to check things. ADON F did not know who the nurse manager over Resident #72's hall was. The resident was present and was unable to say how long the call light had been not working. During an interview on 10/10/22 at 4:50 PM, the DON said the nurses did care and companion rounds Monday through Friday before the morning meeting. She said during those rounds, the nurse was supposed to see if the resident had any complaints and if the room was clean, including the call light being within reach. She stated Resident #72 had a lot of behaviors and she did not know if he ripped the call light out of the plug or what. She said ADON F sent her a picture of it, and she did not know how it got broken. During an interview and observation on 10/11/22 at 1:33 PM, the Administrator stated his expectation for call lights were that they were working, answered in a timely manner and within reach of the residents. He stated there was no time it was acceptable for resident not to have a call light. He stated he was informed by the staff of the call light. The Administrator said he was under the impression that the resident ripped the call light out of the wall because he could be extremely combative. He said he did not know how it got ripped out, but it needed to be replaced . He was informed there was no cord observed in the room and said he did know how that happened. He did bring up the picture of what ADON F sent him. Surveyor explained that where the cord was facing away from the resident, if the resident pulled it out of the wall himself, it would face the resident. The Administrator pulled the Corporate Maintenance Director and showed him the picture. The Corporate Maintenance Director stated he had never seen a call light cord be pulled out of the plug like that because they were designed to come out of the wall and sound. After more discussion the Administrator stated if the resident pulled the cord out himself it would be straight down, and his bed was too far away from the plate for that. Review of the facility's undated Policy and Procedure on Call Lights revealed: Purpose: to respond to a resident's call light for their needs. Equipment: functioning call light. Procedure: if the call light does not work, it is important to report it to the charge nurse who in turn will notify the maintenance supervisor. The call light must always be within resident's reach before you leave the room. Review of the facility's undated Policy and Procedure on Resident Call Systems documented: The nurses' station is equipped to receive resident calls through a communication system from resident at each resident's bedside and at toilet, shower and bathing facilities. The call system shall be accessible to a resident lying on the floor. The call system in resident room will be accessible to alert, confined residents and confused residents and the residents will be instructed to it's' availability and location. 676348 Page 7 of 7