Health inspection·June 6, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #16) of 3 residents reviewed for enteral feeds. The facility failed to ensure Resident #16's enteral feed was properly administered at the correct rate of infusion. This failure could place residents at risk of not receiving the proper nutritional requirements prescribed by the physician. Findings included: Review of Resident #16's MDS revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a group of neurological disorders that permanently affect movement and muscle coordination), lung disease, anemia, aphasia (inability to speak), anemia, coronary artery disease, and gastroesophageal reflux disease. Review of Resident #16's annual MDS, dated [DATE], documented that his BIMS score should not be calculated due to the resident was rarely/never understood, and the BIMS scoring was not conducted. His Functional Status indicated he was totally dependent on staff for all his ADLs. Review of Resident #16's care plan, dated 04/17/24, revealed he was non-verbal and was totally dependent on staff for all ADLs and activities. Record review on 06/06/24 at 10:02 AM of resident #16's physician orders reflected the physician discontinued the order for tube feeding at 75 ml/hr and reordered the tube feeding for 70 ml/hr on 06/05/24. Observation on 06/06/24 at 9:45 AM revealed Resident #16 was in bed with the head of the bed elevated, and a feeding pump at the bedside was infusing the enteral feeding at a rate of 75 ml/hr. Observation of the bag of formula hanging revealed it had been labeled with a rate of 75 ml/hr, with a date of 6/06/24, and a time of 02:00 a.m. This rate was 5ml/hr more than the new order. Interview on 06/06/24 at 09:46 AM with LVN A revealed the tube feeding rate was changed by order yesterday and that he had decreased the rate on the pump to 70 ml/hr yesterday. He reported that in an off-going nurse report this morning, the nurse told him there were no changes. Following the Page 1 of 15 676358 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview, LVN A reviewed the order, acknowledged the mistake, and immediately returned to the resident's room to change the feeding rate from 75 ml/hr to 70 ml/hr. Interview on 06/06/24 at 11:10 AM, the DON stated that the expectation for tube feedings was that the nurse looked at the orders to hang it up. He reported that running the tube feeding at the wrong rate might affect a resident in that it could cause weight gain. He acknowledged that it could possibly cause weight loss and choking as well. Interview on 06/06/24 at 01:16 PM, ADON C stated that regarding administering tube feeding, the nurse was expected to check the orders. Double-check it. Then, set the pump to the correct rate. If they get too much, it's a medical error. She stated this resident (Resident #16) was gaining a lot of weight. So, they decreased it yesterday. The dietician adjusts it according to weekly weights. She reported that a resident receiving too much tube feeding could experience aspiration, pneumonia, distention, and too high residuals. In an interview on 06/06/24 at 01:23 PM, LVN D stated that nurses first review the order when administering tube feedings: right patient, passage, birthdate, condition, and time. She stated that new orders were immediately changed in the system. She stated that if the rate [NAME] too fast, the guest could get too full too fast, and have bloating, displacement of the tube, and aspiration. Interview on 06/06/24 at 02:20 PM: The DON reported he was aware of a patient receiving the wrong tube feeding rate. He stated he had contacted the night nurse, LVN B, regarding resident #16 receiving tube feeding at the incorrect rate last night. The DON reported that LVN B had stated that she made a mistake and didn't see the order. The DON reported that the facility also did not have their typical 09:00 clinical meeting this morning, during which they usually review all changed resident orders. He reported doing a 1:1 teaching with LVN B. Record review of the facility's policy, undated, titled, Policy and Procedure No.: NSG-5.095 Titled: Enteral Nutrition for Closed System Nasogastric, Nasointestinal, Gastric, and Jejunal Feeding Tubes, Revised January 12, 2020; May 19, 2023, was reviewed. Number 3 in the procedure states, Check physician's order for formula, route, rate, and frequency. 676358 Page 2 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for one (#38) of two residents reviewed for oxygen orders. Residents Affected - Few The facility failed to administer oxygen for #38 as ordered by the physician. This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health. The findings included: Review of #38 's Face Sheet dated 06/06/24 revealed she was admitted to the facility on [DATE] and readmitted on 4/30/24 with diagnoses including acute respiratory failure (when your lungs cannot release enough oxygen into blood, which prevents organs from properly functioning). Resident #38's entry MDS, dated [DATE], revealed she had intact cognition with a BIMS score of 13. She required Oxygen therapy. Review of Resident #38's physician order, dated 05/03/24, revealed that the physician ordered the resident to be on 2 LPM (liters per minute) Inhalation every shift via nasal canula for acute respiratory failure, unspecified whether with hypoxia or hypercapnia. Review of Resident #38's Care Plan initiated on 05/03/24 revealed problem Respiratory Failure. Goal: Oxygen 2 Liter per Minute Inhalation every shift. The intervention was to administer medications, respiratory treatments, and oxygen as ordered. Observation on 06/04/24 at 10:49 AM revealed #38 seated on her chair without using oxygen at 2L/min continuous per nasal cannula as was ordered by the physician. Oxygen tubing was observed on the top of her bed. #38 stated she used the oxygen at night. Observation on 06/04/24 at 02:20 PM revealed Resident #38 seated on her chair without using oxygen at 2L/min continuous per nasal cannula as was ordered by the physician. Oxygen tubing was observed on the top of her bed. #38 stated she used the oxygen at night and was not sure whether it was supposed to be continuous. Observation on 06/05/24 at 02:20 PM revealed #38 seated on her chair without using oxygen at 2L/min continuous per nasal cannula as was ordered by the physician. Oxygen tubing was observed on the top of her bed. Interview with LVN D on 06/05/24 at 3:50 PM revealed she was assigned to take care of Resident #38. She stated when she reported in the morning around 5:45 am the resident was usually on oxygen and during the day she was not on it. LVN D stated she thought it was as needed. She was observed checking the orders and she revealed Resident #38 was supposed to be on oxygen every shift. LVN D stated failure to administer as per the doctors' orders could predispose Resident#38 to shortness of breath, hypoxia, and confusion. She stated she had done training on oxygen administration 676358 Page 3 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0695 . Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 06/06/24 at 11:00 AM revealed that all the nurses were expected to follow physician orders for oxygen therapy. The DON stated he had talked during monthly meetings on oxygen monitoring, and he had not done an in-service since that was not an issue before. The DON stated failure to administer oxygen would lead to rehospitalization. Residents Affected - Few Review of the facility's policy titled applying an oxygen delivery device, with a revised date of January 2020, revealed validate physician orders. 676358 Page 4 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

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. Based on observations, interviews, and record review, the facility failed to 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 on two of four medication carts (100 and 300 Halls nurses' carts) and 2 of 3 staff (LVN E and LVN G) reviewed for pharmacy services. The facility failed to ensure 100 and 300 halls nurses medication cart contained accurate narcotic logs for Residents #35 and #75. LVN E and LVN G failed to document the administration of narcotic medications in a correct and timely manner. This failure could place residents at risk for drug diversion and delay in medication administration. Findings included: Observation on 06/05/24 at 11:29 AM of the nurses' medication cart for hall 100 and the narcotic administration record, with LVN E, revealed the following information: Resident #35's narcotic administration record sheet for Tramadol 50 mg was last signed off on 06/5/24 for a one-tablet dose given at 08:00 AM, for a total of 17 pills remaining while the blister pack count was 16 pills. Resident #75's narcotic administration record sheet for sheet for Hydrocodone-Acetaminophen 5/325 mg was last signed off on 06/5/24 for a one-tablet dose given 08:00 AM, for a total of 50 pills remaining while the blister pack count was 49 pills. Interview with LVN E on 06/05/24 at 12:00 PM, revealed she administered Tramadol 50 mg 1 tablet to Resident #35 and the Hydrocodone-Acetaminophen 5/325 mg 1 tablet to Resident #75 every 8 hours for pain and had not signed off on the NAR . She stated she gave the resident the medication, but she forgot to document it on the medication administration record and sign off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration, but she did not because she got busy. She stated failure to sign after administration could lead to medication error. Interview with LVN E on 06/06/24 at 09:59 AM, revealed she had given Resident#75 Hydrocodone-Acetaminophen 5/325 mg 1 tablet earlier than it was scheduled, and she documented she had administered at 01:00PM. She admitted she did not administer as scheduled and stated she accepted the error. She could not tell whether she had done any training on medication administration. Observation on 06/05/24 at 12:14 PM, of the nurses' medication cart for hall 300 and the narcotic administration record, with LVN G, revealed the following information: Resident #105's narcotic administration record sheet for Lorazepam 0.5mg was last signed off on 06/5/24 for a one-tablet dose given at 8:00 PM, for a total of 22 pills remaining while the blister 676358 Page 5 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0755 pack count was 21 pills. Level of Harm - Minimal harm or potential for actual harm Interview with LVN G on 06/05/24 at 12:27 PM, revealed he administered Lorazepam 0.5 mg 1 tablet to Resident #105 as needed for anxiety and he had not signed off on the NAR. He stated he gave the resident the medication, but he forgot to sign off on the narcotic administration log. He stated he knew he was to sign-out on the narcotic count sheet immediately after administration. He stated failure to do that could lead to a narcotics diversion, medication error, and forgetting to administer. He stated he had done an in-service on medication administration. Residents Affected - Some Interview on 06/05/24 at 3:13 PM, the DON revealed his expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. He stated he had not done an in-service recently, but he had done the skills check off on medication administration and no documentation was provided. Interview on 06/06/24 at 10:30 AM, the DON revealed he had talked with LVN E and he notified her she could only administer medications when scheduled. He stated he would do an in-service with LVN E on the medication error.Reisdnet #75 was scheduled every 8 hours Interview with #75 on 06/06/24 at 03:45 PM, through interpreter revealed she got her pain pills when in pain. Interview with #35 on 06/06/24 at 03:59 PM, he would not tell whether he received a pain pill or not . Review of the facility current Medication-Controlled Substances policy requested and was not given 676358 Page 6 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

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 observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and were labeled in accordance with currently accepted professional principles for 4 (#102, #167, #170, and #175) of 10 residents reviewed for pharmacy services. The facility failed to ensure Residents #102 bottle of nystatin powder medications was securely stored in the medication room or medication cart. The facility failed to ensure Resident, #167,budesonide 160 mcg-glycopyr 9 mcg\formot 4.8 mcg/actuation HFA inhaler, albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler ,a box of ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 mL nebulization solution, were securely stored in the medication room or medication cart. The facility failed to ensure Resident #170, a bottle of ibuprofen 200mgs tablets were securely stored in the medication room or medication cart. The facility failed to ensure Residents #175, a bottle of Vitamin C tablets were securely stored in the medication room or medication cart. These failures could place residents at risk of overdosing, interactionfection, and missing a dose. Findings included: 1. Review of Resident #102's face sheet, dated 06/05/24, revealed the resident was a [AGE] year-old female with an admission date of 05/08/24. Resident 102's diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection). Review of Resident #102's entry MDS, dated [DATE], revealed she had intact cognition with a BIMS score of 15. Review of Resident #102's care plan updated on 05/31/24, reflected:(problem: *Skin Breakdown: At risk for/actual.[05/31/2024]. Goal: Resident will maintain clean and intact skin over the next 90 days [05/08/24 : Onset)*Measures will be taken to prevent skin breakdown over the next 90 days [05/08/24. Open area will be healed over the next 90 days [05/08/24 : Interventions : Apply protective or barrier lotion after incontinence[05/09/24. Resident #102's care plan did not reflect anything regarding being able to self-administer any medications. Review of Resident #102's physician order, dated 06/04/24, revealed she had no order for nystatin 100,000 unit/gram topical powder. Review of Resident #167's face sheet, dated 06/05/24, revealed the resident was a [AGE] year-old male with an admission date of 05/20/24. 676358 Page 7 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #167's Entry MDS assessment, dated 05/24/24, reflected the resident was a [AGE] year-old male with admission date of 05/20/24. Resident #167's diagnoses included acute respiratory failure with hypoxia and chronic obstructive pulmonary disease with (acute) exacerbation). Resident #167 had moderate cognitive impairment with a BIMS score of 11. Review of Resident #167 's care plan dated 5/20/24, reflected: Problem em: DX of chronic obstructive pulmonary disease [05/20/24. Goal: Resident will demonstrate an effective respiratory rate, depth, and pattern over the next 90 days. Intervention: Adjust head of bed and body positioning to assist ease of respirations. Administer medications, respiratory treatments, and oxygen as ordered. Administer Nebulizer treatments as ordered. Monitor lung sounds, pallor, cough, and character of sputum. Monitor respiratory rate, depth, and effort. Notify Medical D octor and family of any change of condition. Review of resident #167's physician order dated 05/20/24 revealed resident #146 had orders for ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 ml nebulization solution (ipratropium bromide/albuterol sulfate) 1 ampul inhalation every 6 hours as needed wheezing nebulization, budesonide 160 mcg-glycopyrrolate 9 mcg-formot 4.8 mcg/actuation inhaler (budesonide/glycopyrrolate/formoterol fumarate) 2 puffs inhalation 3 times per day as needed, and albuterol sulfate 90 mcg/actuation aerosol inhaler (albuterol sulfate) 2 puffs inhalation every 6 hours as needed. Review of Resident #170's face sheet, dated 06/06/24, revealed the resident was a [AGE] year-old female with an admission date of 05/25/24. Resident 170's diagnoses included high blood pressure. Review of Resident #170's entry MDS, dated [DATE], revealed she had intact cognition with a BIMS score of 15. Review of Resident #170's care plan updated on 05/26/24, did not reflect anything regarding being able to self-administer any medications. Review of Resident #170's physician order, dated 06/04/24, revealed she had no order for ibuprofen tablets. Review of Resident #175's face sheet, dated 06/05/24, revealed the resident was an [AGE] year-old male with an admission date of 05/25/24. Resident 175's diagnoses included acute kidney failure (the rapid loss of your kidneys' ability to remove waste and help balance fluids and electrolytes in the body). Review of Resident #175's entry MDS, dated [DATE], revealed he had intact cognition with a BIMS score of 14. Review of Resident #175's care plan updated on 06/04/24, revealed problem, Self-Administration: Goal: Resident will take medications safely and as prescribed. Monitor resident's self-administration frequently. (This was updated after the facility was notified of a resident having a bottle of Vitamin c in the room). Review of Resident #175's physician order, dated 06/04/24, revealed ascorbic acid (vitamin C) 500 mg tablet (ASCORBIC ACID) 1 tablet by mouth 1 time per day, (after the facility was notified of him being in possession of vitamin C bottle). 676358 Page 8 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 06/04/24 at 10:21 AM revealed Resident #102 in her room, seated on her chair watching TV. There was a bottle of 100,000 unit/gram topical powder on resident's bedside table. Resident #102 stated she brought the powder from the hospital, and she does not think the facility was aware that she had it. She stated, she applied it on her abdominal folds. Observation and interview on 06/04/24 at 10:29 AM revealed Resident #175 in his room, seated on his bed. There was a bottle of white tablets labelled Vitamin C on the resident's bedside table. Resident #175 stated he has been in the facility for one month. Resident #175 revealed the medications were brought by his family member and he took 1 tablet every day. He stated staff were aware, they see them all the time. He stated he was not aware whether he was supposed to keep the medication in his room and he used the inhaler and nebulizer once a day. He revealed he had the medications in his room all through his stay. Observation and interview on 06/04/24 at 10:39 AM revealed Resident #170 in her room, seated on her bed. There was a bottle of ibuprofen 200mg tablets on the resident's bedside table. Resident #170 stated he has been in the facility for one week. Resident #170 revealed the medications were hers and she took them as needed for pain. Observation and interview on 06/05/24 at 07:53 AM revealed Resident #167 in his room, seated on his bed. There was budesonide 160 mcg-glycopyr 9 mcg\formot 4.8 mcg/actuation HFA inhaler, albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler , and a box of ipratropium 0.5 mg-albuterol 3 mg (2.5 mg base)/3 mL nebulization solution on resident's bedside table. Resident #167 stated he has been in the facility almost one month and he used the inhaler and nebulizer once a day. He revealed he had the medications in his room all through his stay. Observation and interview on 06/04/24 at 1:57 PM with LVN D revealed resident #102,#175, and #170 had medications in their rooms. LVN B stated the resident should not have any medication in their rooms. LVN D revealed she was the nurse assigned to Resident #102, 170, and #175. LVN D stated she was in the resident's room earlier and did not see any medications in the room. She stated all medications needed to be secured to ensure the resident's safety. LVN D stated they had not been assessed for self-administration and they do not have residents that self-administer medications in the facility. LVN D stated, she collected all the medications, and she notified the doctor, that the staff will be administering those medications to the residents. LVN D stated it was the nurse's responsibility to check the rooms and give back the medications to families. She stated she had done training on medication storage. Interview on 06/04/24 at 02:04 PM with the ADON J revealed her expectation was that the staff should be checking for medications in the rooms and if found they call the doctor for orders and notify families. ADON J stated her expectation was all residents were to remain safe. She stated in case of self-administration of medication residents had to be reviewed by the doctor, an assessment done, and they have to be fully alert. ADON J stated the facility did not have residents that self-administered medications. ADON J stated the risk of leaving medication in rooms was that it could lead to another resident taking the medication and adverse reaction. She stated the facility had done in-services with the staff on checking residents' rooms and removing medications from the rooms. In-services were requested and not provided. Interview on 06/04/24 at 02:30 PM with the DON revealed his expectation was that no resident was allowed to keep medication in their rooms. He stated the problem were the families and they educate them during admission not to bring medication into the facility. The DON stated the risk of leaving 676358 Page 9 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0761 medication in rooms was that it could lead to another resident taking the medication. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Medication Storage policy, dated September 2018, did not reflected on medications stored at bedside for self-administration. Residents Affected - Some 676358 Page 10 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

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 observations, interviews, and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for kitchen sanitation. The facility failed to ensure the ice machine scoop, located in the facility's kitchen, was thoroughly cleaned. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 06/04/24 at 08:40 a.m. in the facility's only kitchen reflected: Observation of the ice machine scoop, in the facility kitchen revealed the inside of the scoop holder held about a half inch of water and gray color buildup floating in the water. In an interview on 06/04/24 at 8:42 a.m. with the Dietary Manager, she stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. She was holding the ice machine scoop holder in her hand when the area of concern was discovered. She stated she had trained staff to clean the ice machine and scoop holder every two or three days. She handed the ice machine scoop holder and ice scoop to an aide and instructed her to run it through the dishwasher. She stated she would in-service staff to run the ice scoop holder and ice scoop through the dish washer each night after dinner. She stated this risk could result in the spread of germs and bacteria that can cause the residents to get sick . Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 676358 Page 11 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

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 observations, interviews, 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 2 of 2 Residents (Residents #16 and #31) reviewed for infection control. Residents Affected - Some The facility failed to ensure LVN A used appropriate hand hygiene when providing medications through a feeding tube to Resident #16 and #31. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings included: 1. Record review of Resident #16's face sheet, dated 06/06/24, revealed a [AGE] year-old male, admitted to the facility on , with diagnoses that included Cerebral palsy (a group of conditions that affect movement and posture) and Dysphagia. Record review of Resident #16's most recent quarterly MDS assessment, dated 05/07/24 revealed the resident was severely cognitively impaired and he required a feeding tube or abdominal (PEG) (endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) Record review of Resident #16's comprehensive care plan, revision date 03/08/24 revealed the resident had swallowing difficulty, had a feeding tube related to dysphagia, risk for aspiration, weight loss, and aspiration. Resident will tolerate tube feeding without complications over the next 90 days. 2.Record review of Resident #31's face sheet, dated 06/06/24, revealed a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included Non-Traumatic Brain Dysfunction (any brain injury not caused by external physical force, such as a blow to the head) and Dysphagia. Record review of Resident #31's most recent quarterly MDS assessment, dated 02/29/24 revealed the resident was severely cognitively impaired and he required a feeding tube - nasogastric or abdominal (PEG)(an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall). Record review of Resident #31's comprehensive care plan, revision date 02/08/24 revealed the resident had swallowing difficulty had a feeding tube related to dysphagia, risk for aspiration, weight loss, and aspiration. Resident will tolerate tube feeding without complications over the next 90 days. Observation on 6/5/24 at 12:30 PM, during the medication pass, LVN A washed his hands and put on gloves and gown since Resident#31 was on enhanced precautions due to gastronomy tube. LVN A then returned to the medication cart, obtained keys from his pocket, and opened the cart and got baclofen 10mgs. He crushed and put it in a cup. LVN A put the keys in his pocket. He then went to the bathroom sink got water in a cup and went to the bedside. He used the bed controller to [position the resident and then off the feeding pump . LVN A used the same gloves he had placed in his scrub pocket, touched the bed control pad, he did not change gloves or use appropriate hand hygiene, and continued with 676358 Page 12 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0880 the medication administration. Level of Harm - Minimal harm or potential for actual harm Observation on 6/5/24 at 12:46 PM, during the medication pass, LVN A washed hands and put on gloves and gown since Resident#16 was on enhanced precautions due to the gastronomy tube. LVN A then returned to the medication cart, obtained keys from his pocket, opened the cart got Lactulose 15mls, Sucralfate 10mls, and Lorazepam 2 mgs 1 tablet. He prepared and put in different cups. LVN A put the keys in his pocket. He then went to the bathroom sink, got water in a cupcup, and went to the bedside. LVN A with the help of a C N A ( name unknown) they were observed positioning and pulling the resident up in bed. He used the same gloves he had placed in his scrub pocket, did not change gloves, or use appropriate hand hygiene, and continued with the medication administration. Residents Affected - Some Interview on 6/5/24 at 01:04 PM with LVN A revealed, he was supposed to wash hands before contact with Resident#16 and #31. He stated he was supposed to change gloves and sanitize before administering medications to prevent contamination. He stated he had done an in-service on infection control. Interview on 6/5/24 at 3:25 PM., the DON stated, it was his expectation the nurse should practice appropriate hand hygiene. He stated the facility policy stated staff should perform hand hygiene before they start administering medication through gastronomy tube. He stated the nurses should wash hands and wear gloves once they prepare the medications. He stated he had an in-service on hand washing and he reminded them on monthly meetings to prevent contaminiation. Record review of the facility in-services it was revealed the facility offered infection: Handwashing/equip cleaning in-service on 3/12/24 during the nurse team meeting. Record review of the facility policy and procedure, titled hand hygiene for staff and resident, reviewed date January 2022 revealed in part, .1. Hand hygiene is done: Before resident contact and after resident contact. I. Contact with a resident's intact skin .lifting the resident in bed. J. Contact with environmental surfaces in the immediate vicinity of resident. 676358 Page 13 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. Residents Affected - Some On 6/04/24 and 6/05/24 Flies and gnats were observed in multiple areas of the facility to include kitchen, dining room, hall 700, hall 500. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 06/04/24 at 8:40 a.m. revealed three flies and six gnats flying around the kitchen. Observation on 06/05/24 at 9:00 a.m. revealed a fly and two gnats on the 700-hall flying around the breakfast cart as the dietary aide passed out breakfast trays. Observation on 06/05/24 at 10:30 a.m. revealed a fly crawling across the nurse's station. Observation on 06/05/24 at 9:45 a.m. revealed a fly flying on hall 500. Observation and interview on 06/05/24 at 11:50 a.m. revealed two gnats flying near the exit door located next to the Dietary Manager's office. Interview with the Dietary Manager revealed that she was aware there were pests in the kitchen. She stated she reported it to the Maintenance Director who will contact pest control. The Dietary Manager stated pest control was present in the kitchen on 6/05/24. She stated the presence of pests can cause harm to the residence by spreading germs and bacteria. Interview on 06/06/24 at 10:35 a.m. with Resident #39 revealed she had roaches in her shower but contacted the Maintenance Director and he came and sprayed, then a few days later the pest control company came out and treated and they had no issues since. Interview on 06/06/24 at 11:20 a.m. with the housekeeper revealed she had noticed an increase of gnats flying around. When she noticed them, she will call the maintenance director. She stated pest control comes biweekly. In an interview on 06/06/24 at 1:14 p.m. with the Maintenance Director revealed that the Pest Control company came to the facility two times per month. Additionally, they would come out the same day if he called them. The Maintenance Director stated there had been flies/gnats in the facility. He stated there was no structural damage to the facility that would allow pests to enter the facility. He stated he was not able to use any over-the-counter products to spray for bugs, everything must be commercial grade. They have blue light sticky strip chemicals to attract flies and gnats located in the kitchen and the dining areas that were cleaned out when pest control came to the building. He stated there were no residents or staff that had complained about them. The Maintenance director stated that gnats and flies could carry germs that could cause infection control problems . Record review of facility provided pest control log revealed, in part, dates and treatments as follows: 676358 Page 14 of 15 676358 06/06/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0925 Level of Harm - Minimal harm or potential for actual harm Treated areas were interior perimeter in kitchen, laundry room, dining room, employee break room, rest room, and exits preventative for ants, roaches, crawling insects, and other occasional invaders. Target: Filth Flies (house or blow), Cluster flies, Drain flies, flesh flies, fungus gnats, house flies, large filth flies, night fliers, and phorid flies. Residents Affected - Some Other dates at the facility 5/21; 5/3; 4/16; 4/1 676358 Page 15 of 15