Health inspection·May 17, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 6 residents (Resident #1) reviewed for resident rights; in that: Residents Affected - Few The facility failed to ensure Resident #1's call lights was within reach. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #1's admission record, dated 05/15/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), ventricular tachycardia (cardiovascular disorder in which fast heart rate occurs in the ventricles of the heart), dementia (a syndrome associated with many neurodegenerative diseases which is characterized by general decline in cognitive abilities that impacts a person's ability to perform everyday activities), and heart failure (a syndrome caused by impairment in the hearts ability to fill with and pump blood). Record review of Resident #1's quarterly MDS assessment, dated 03/21/24, reflected Resident #1 had a BIMS score of 12, which indicated the resident was moderately cognitively impaired. The MDS reflected resident had active diagnoses of osteoarthritis and a history of falling. Record review of Resident #1's care plan, initiated 02/21/18, reflected Resident #1 was care planned for ADL self-care performance deficit r/t Dementia with a goal of maintain current level of function through the review date. and had an intervention of The resident requires extensive assistance) by (X 1) staff for toileting. and Encourage the resident to use call light to call for assistance. assist bar for assistance with bed mobility. In an observation on 05/14/24 at 10:34 AM, Resident #1's call light was out of the resident's reach. Resident #1's call light was lying in between the mattress and bed frame and slightly hanging down. Call light was not visible to the eyes unless bending all the way down to see under the head of the bed. Resident #1 was sitting up in her wheelchair close to the foot of her bed. Resident #1 demonstrated that she could not find or reach the call light. In an interview on 05/14/24 at 10:35 AM, Resident #1 stated she was wonderful, and the staff Page 1 of 26 676386 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treated her great and could not have been better. She stated the staff helped her with everything. She stated she did not have her call light and could not find it. She stated she usually had it where she could get to it, but she could not find it at that time. In an observation on 05/14/24 at 12:15 PM, revealed Resident #1's call light was lying in between the mattress and bed frame and slightly hanging down and out of Resident #1's reach. In an interview on 05/14/24 at 11:19 AM, RN A stated she had been trained on call lights recently. She stated she could not remember when the last in-service was, but it had not been too long ago. She stated if a residents call light was out of reach, the resident would not be able to call for help if needed. She stated sometimes Resident #1 moved things around in her room but when she saw the call light under the mattress, she knew resident could not have done that. She stated she removed call light from under mattress and placed call light in residents reach. In an interview on 05/15/24 at 10:44 AM, the ADON stated all staff had been trained on call lights and making sure call lights were in residents reach at all times. She stated they just recently had an in-service on call lights. She stated call lights should have been in residents reach at all times. She stated if a call light was not in a residents reach, it could cause falls, angry residents or families, or many other negative things. In an interview on 05/16/24 at 12:11 PM, the ADM stated staff had been in-serviced and trained on call light placement and response. She stated call lights should be in residents reach at all times. She stated if a residents call light was not in reach it could cause the resident to have a fall and the resident would not be able to call for help. In an interview on 05/16/2024 at 12:32 PM, the DON stated staff was in-serviced recently on call light placement and response. She stated residents' call lights should always be in reach. She stated if a resident's call light was out of reach the resident could possibly be at risk of falls, choking, or not getting the help they need. She stated if a call light was not in reach, it could possibly be detrimental to a residents' health or even lead to death. Record review of undated facility policy titled Call Light revealed Licensed nurse and nurse aide 1. To respond promptly to resident's call for assistance, 2. To assure call light system is functioning properly, Procedure: 1. All nursing personnel must be aware of call lights at all times. 6. When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the resident is and show him/her how to use the call light. Record review of the facility's in-service titled Resident Care and Call Lights dated 04/22/24 revealed staff had been in-serviced regarding call lights and in-service stated Residents must be able to contact staff at all times. When they are in their room it is important that they have access to their call bell. All staff are to make sure that call lights are within reach of the resident when they are in their rooms. If a resident is in bed and then transferred to a chair or wheelchair, make sure the call light is also transferred. 676386 Page 2 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility to ensure that the residents had the right to and that the facility promoted and facilitated resident self-determination through support of resident choice for 26 (Resident #'s 1, 3, 6, 10, 14, 15, 16, 17, 20, 25, 28, 36, 37, 41, 42, 46, 47, 67, 68, 79, 83, 92, 96, 105, 107, and 362) of 26 residents whose care was reviewed, in that: 1) The facility denied Resident #16 the right to sell her car by declaring her incompetent to make her own decisions. 2) The facility was applying an order for all (Resident #'s 1, 3, 6, 10, 14, 15, 16, 17, 20, 25, 28, 36, 37, 41, 42, 46, 47, 67, 68, 79, 83, 92, 96, 105, 107, and 362) residents upon admission related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. This deficient practice could place residents with the ability to make choices at risk of having their rights violated, resulting in diminished quality of life, unmet needs, and unable to have wishes met in the event of a life threatening emergency . The finding include: Resident #16 Record review of an undated face sheet reflected Resident #16 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #16 had the following diagnoses of acute respiratory failure, unspecified severe protein calorie malnutrition, chronic heart failure, and hypotension (low blood pressure). Record review of Resident #16's MDS dated [DATE] reflected she had a BIMs score of 14 indicating she was cognitively intact. The MDS also reflected Resident #16 required assistance with dressing and grooming and used a manual wheelchair for mobility. Record review of a Physicians Order Summary Report dated 05/15/24 for Resident #16 reflected an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. In an interview with on 05/14/24 at 10:45 a.m., Resident #16 was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident #16 stated she attempted to sell her car with the help of her family and was unable to do so. Resident #16 stated the facility informed me at that time I was not competent to sell my car. She stated, she has her right mind to make her decisions. Her family member in the room stated we had no idea she had been declared medically incompetent. 676386 Page 3 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Resident #1 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's MDS dated [DATE] reflected Resident #1 had impaired short-term and long-term memory . Residents Affected - Some Record review of Resident #1's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #3 Record review of Resident #3's MDS dated [DATE] reflected Resident #3 had a BIMS score of 15 indicating Resident #3 was cognitively intact. Record review of Resident #3's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. In an interview on 05/14/24 at 09:12 a.m., Resident #3 was alert and able to indicate was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident #3 states she can make her own decisions. Resident #6 Record review of Resident #6's MDS dated [DATE] reflected Resident #6 had a BIMS score of 10 indicating Resident #6 had moderate cognitive impairment. Record review of Resident #6's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #10 Record review of Resident #10's MDS dated [DATE] reflected Resident #10 had a BIMS score of 12 indicating Resident #10 had moderate cognitive impairment. Record review of Resident #10's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #14 Record review of Resident #14's MDS dated [DATE] reflected Resident #14 had a BIMS score of 15 indicating Resident #14 was cognitively intact. Record review of Resident #14's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. 676386 Page 4 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Resident #15 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #15's MDS dated [DATE] reflected Resident #15 had a BIMS score of 13 indicating Resident #15 was cognitively intact. Residents Affected - Some Record review of Resident #15's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #17 Record review of Resident #17's MDS dated [DATE] reflected Resident #17 had a BIMS score of 14 indicating Resident #17 was cognitively intact. Record review of Resident #17's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #20 Record review of Resident #20's MDS dated [DATE] reflected Resident #20 had a BIMS score of 2 indicating Resident #20 was cognitively impaired. Record review of Resident #20's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #25 Record review of Resident #25's MDS dated [DATE] reflected Resident #25 had a BIMS score of 12 indicating Resident #25 had moderate cognitive impairment. Record review of Resident #25's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #28 Record review of Resident #28's MDS dated [DATE] reflected Resident #28 had a BIMS score of 10 indicating Resident #28 had moderate cognitive impairment. Record review of Resident #28's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #36 Record review of Resident #36's MDS dated [DATE] reflected Resident #36 had short-term and long-term memory problems. 676386 Page 5 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #36's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #37 Residents Affected - Some Record review of Resident #37's MDS dated [DATE] reflected Resident #37 had a BIMS score of 15 indicating Resident #37 was cognitively intact. Record review of Resident #37's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #41 Record review of Resident #41's MDS dated [DATE] reflected Resident #41 had a BIMS score of 15 indicating Resident #41 was cognitively intact. Record review of Resident #41's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #42 Record review of Resident #42's MDS dated [DATE] reflected Resident #42 had had short-term and long-term memory problems. Record review of Resident #42's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #46 Record review of Resident #46's MDS dated [DATE] reflected Resident #46 had a BIMS score of 5 indicating the resident was cognitively impaired. Record review of Resident #46's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #47 Record review of Resident #47's MDS dated [DATE] reflected Resident #47 had a BIMS score of 10 indicating Resident #47 had moderate cognitive impairment. Record review of Resident #47's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. 676386 Page 6 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Resident #67 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #67's MDS dated [DATE] reflected Resident #67 had a BIMS score of 11 indicating Resident #67 had moderate cognitive impairment. Residents Affected - Some Record review of Resident #67's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #68 Record review of Resident #68's MDS dated [DATE] reflected Resident #68 had short-term and long-term memory problems. Record review of Resident #68's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #79 Record review of Resident #79s MDS dated [DATE] reflected Resident #79 had short-term and long-term memory problems. Record review of Resident #79's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #83 Record review of Resident #83's MDS dated [DATE] reflected Resident #83 had a BIMS score of 8 indicating Resident #83 had moderate cognitive impairment. Record review of Resident #83's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #92 Record review of Resident #92's MDS dated [DATE] reflected Resident #92 had a BIMS score of 9 indicating Resident #92 had moderate cognitive impairment. Record review of Resident #92's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #96 Record review of Resident #96's MDS dated [DATE] reflected Resident #96 had a BIMS score of 13 indicating Resident #96 was cognitively intact. 676386 Page 7 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #96's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #105 Residents Affected - Some Record review of Resident #105's MDS dated [DATE] reflected Resident #105 had a BIMS score of 5 indicating Resident #105 was cognitively impaired. Record review of Resident #105's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #107 Record review of Resident #107's MDS dated [DATE] reflected Resident #107 had a BIMS score of 8 indicating Resident #107 had moderate cognitive impairment. Record review of Resident #107's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. Resident #362 Record review of Resident #362's MDS dated [DATE] reflected Resident #362 had a BIMS score of 7 indicating Resident #362 was cognitively impaired. Record review of Resident #362's Physicians Order Summary Report dated 05/15/24 had an order related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. signed by the physician. In an interview on 05/14/24 at 09:30 a.m., Resident #362 was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident # 362 states he can make his own decisions. In an interview on 05/14/24 at 09:34 a.m., Resident #37 was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident #37 states she can make her own decisions. In an interview on 05/14/24 09:58 a.m., Resident #14 was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident #14 states she can make her own decisions. In an interview on 05/14/24 at 10:45 a.m., Resident #16 was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident Stated she attempted to sell her care with the help of her son and was unable to do so. The facility informed me at that time I was not competent to sell my car. She stated she has her right mind to make her decisions. 676386 Page 8 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 05/14/24 at 02:10 p.m., Resident #67 was not aware of this order stating that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. Resident #67 states he can make his own decisions. In an interview on 5/15/24 at 10:15 a.m., the DON stated every resident received this physician statement order upon admission. Staff do determine and reevaluate yearly the physician's statement accuracy. The facility puts the physician statement in place mostly for resident protection to prevent family members from changing POA, taking money, writing checks those types of things. She stated for residents even with a BIMS score of 15 (indicating the resident is cognitively intact) the facility applies the physician statement order. This is because a residents BIMS score may fluctuate from day to day. The ADON is responsible for completing the yearly evaluations and updating the order within the chart. The physician is the one who determines if the resident is or is not capable of making their own decisions. The DON stated this order also was used to assist for making medical necessity for Medicaid services. The DON stated there is no policy to monitor this form provided by the medical director. In an interview on 05/15/24 at 10:41 a.m., MDS A she stated she does all the MDS assessments. She helps with looking at LTMN for Medicaid residents. She stated she looks to see if the resident had cognitive issues, memory issues based off their BIMS, visual problems for meeting long-term care qualifications. MDS A stated she would reach out to the physician to see if there are any additional records or get additional information if needed. She was aware there was an order on the chart that residents are not able to make their own decisions and it says that they are or not able to make their own decisions- whichever they meet. That order also helps with getting LTMN and it falls under the cognitive area when looking for LTMN. MDS A stated the facility had not gone through the court system to get a guardian for residents who cannot make their own decisions not to her knowledge. In an interview on 05/15/24 11:08 a.m., the Medical Director said he was aware of the blanket order stating, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. He stated that the order is generally determined upon admission by physical assessment on rounds, visual assessment, not being able to answer simple questions, or by completing a mini mental assessment. The Medical Director stated that to take away a resident right is a broad statement. We as a facility could probably do a better job of determining what is considered not capable of understanding. A resident could have just intermittent confusion that may resolve within a few days such as an acute infection not necessarily making the order valid. On 05/15/24 at 11:21 a.m., in a Confidential meeting attending residents were asked if their physician told them they are not able to make their own decisions, 9 /9 residents verbalized no they were not told. Residents stated they could make their own decisions. A record review of the Medical Practice Agreement for Attending Physicians dated 4/25/19 reflected under admission requirements that the Medical Director will provide a physician statement regarding a resident's ability to understand and exercise their rights. A record review of an undated Admissions Agreement for residents titled Your Rights as a Resident reflected: You have the right to be informed, make your own decisions, and have your information kept private. 676386 Page 9 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of and undated facility policy and procedure titled Facility Policy Relating to Self-Determination reflected: A. Provides all individuals, at the time of admission to the nursing facility, with information relating to the individuals' rights under Texas law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives, Physicians and family or surrogates medical power of attorney and declaration for mental health. 676386 Page 10 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0641, Regulation FF14 Residents Affected - Few [NAME], [NAME] Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 10 residents (Residents #83) reviewed for resident assessments. The facility failed to ensure the MDS assessment accurately reflected: Resident #83's moderately impaired vision. This deficient practice could place residents at risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #83's face sheet dated 05/16/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83's diagnoses included sudden visual loss, left eye (loss of the ability to see well or to see at all), anxiety disorder (excessive nervousness, fear, apprehension, and worry), muscle weakness (lack of physical or muscle strength), visual hallucinations (seeing things that aren't real, like objects, shapes, people, animals, or lights), and dementia (loss of cognitive functioning, thinking, remembering, and reasoning) A record review of Resident #83's Quarterly MDS assessment, dated 04/23/24, reflected the resident had a BIMS score of 08, which indicated mildly impaired. Resident #83's Quarterly MDS assessment reflected Resident #83 had moderately impaired vision (limited vision, not able to see newspaper headlines but can identify objects). A record review of Resident #83's Quarterly MDS assessment, dated 03/26/24, reflected the resident had a BIMS score of 05, which indicated severe impaired. Resident #83's Quarterly MDS assessment reflected Resident #83 had highly impaired vision (object identification in question, but eyes appear to follow objects). A record review of Resident #83's Annual MDS assessment, dated 02/11/24, reflected the resident had a BIMS score of 11, which indicated moderately impaired. Resident #83's Annual MDS assessment reflected Resident #83 had severely impaired vision (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). A record review of Resident #83's care plan, dated 03/21/2024, reflected Resident #83 was care planned for impaired visual function r/t sudden complete visual loss. In an interview on 05/16/24 at 10:52 a.m., LVN A stated that Resident #83's vision is severely impaired. LVN A stated she would consider Resident #83's vision as blind. An interview with the DON on 05/16/24 at 12:55 p.m., the DON stated that the MDS coordinator was 676386 Page 11 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0641 Level of Harm - Minimal harm or potential for actual harm responsible for completing the MDS assessment. The DON stated that she was very familiar with Resident #83 and would consider Resident #83's vision to be severely impaired. The DON stated that if a resident was missing teeth, then that should be reflected on the residents' MDS assessment. The DON stated that if the MDS assessment was not accurate then there could be money penalties and they resident might not receive the appropriate care. Residents Affected - Few An interview with the MDS Coordinator on 05/16/24 at 1:05 p.m., the MDS Coordinator stated that she was responsible for completing the MDS assessment accurately. MDS Coordinated stated that the SW was responsible for completing the hearing, speech, and vision section of the MDS assessment. MDS Coordinator stated that if the MDS assessment was not completed accurately then the resident might not receive the appropriate care needed. An interview with the SW on 05/16/24 at 1:35 p.m., the SW stated that she was responsible for completing vision section of the MDS assessment. The SW stated she was familiar with Resident #83 and would consider her vision moderately impaired. The SW stated that Resident #83 could see big objects with her glasses on. An interview with the ADM on 05/16/24 at 2:00 p.m., the ADM stated that Resident #83's vision was highly or severely impaired. ADM stated that Resident #83 has little to no vision in her left eye. The ADM stated that if a resident was missing teeth, then that should be reflected on the residents' MDS assessment. The ADM stated that if a resident MDS assessment was incorrect then that could cause the resident's care plan to be incorrect and the resident may not receive the appropriate care needed. A record review of the facility's MDS Policy, not dated, reflected, Prepare, implement, and evaluate Resident assessments and comprehensive care plan and MDS according to facility guidelines. Correctly and timely record and document any forms on resident care, personnel, and training. Follow all guidelines for MDS set by state and federal. Refer to the RAI manual for interpretation of any and all MDS questions! MDS' will be performed upon admission and every 92 days thereafter at minimum. Resident information will be as accurate and truthful as possible and may be collected and documented in multiple areas. 676386 Page 12 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #67) of 6 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #67's risk for falls resulting in no fall interventions in place for this resident. This failure could place residents of risk for not receiving appropriate care and treatment, lack of fall interventions, a delay in treatment, a decline in health, and hospitalization. Findings included: Record review of an undated face sheet reflected Resident #67 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #67 had the following diagnoses of metabolic encephalopathy (a brain dysfunction caused by problems with brain metabolism), Diabetes Mellitus (elevated blood sugar), Polyneuropathy (nerve damage), and Anemia (low red blood cells). Record review of Resident #67s MDS dated [DATE] reflected he had a BIMs score of 11 indicating resident had moderate cognitive impairment. The MDS also reflected Resident #67 required assistance with dressing and grooming and used a manual wheelchair for mobility. Record review of care plan dated 02/20/24 for Resident #67 reflected a care plan with the focus of resident having actual falls on dates 02/09/24, 03/22/24 and 04/12/24. The care plan goal was that resident would resume his usual activity without further incidents through review date. Interventions was to continue interventions on the at risk for falls care plan. There was no care plan reflecting at risk for falls. Record review of Morse Fall Scale (an assessment to determine if a resident is at risk for falling) dated 5/9/24 reflected Resident #67 scored a 65 indicating he was high risk for falls. In an interview and observation on 05/14/24 at 2:17 PM, Resident #67 was sitting in his wheelchair with no shoes on his feet. He stated he had about 5 falls since his admission. Resident #67 stated the floor was to slick in his room. In an interview on 05/16/24 at 12:00PM, MDS Coordinator A revealed it is the responsibility of the two MDS coordinators to work together to ensure the Care Plans are completed and updated with each fall. She stated the supervising staff (ADM, DON, ADON, MDS) do go over the incidents and accidents daily in the morning meeting. Then the team discuss fall interventions appropriate for that resident. The care plan was updated according to the interventions agreed upon by the team. There should be a risk for falls care plan, and an actual fall care plan to evaluate what interventions work and do not work. The negative effects related to not placing interventions or have a fall care plan would be increased falls with possible injury. In an interview on 05/16/24 at 01:35 PM, MDS Coordinator B stated that interventions on the care 676386 Page 13 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan for falls were updated with each fall. He stated incidents accidents were reviewed in the morning meeting. The care plan then would be updated with a new intervention to assist in the prevention of future falls. He stated there was a list of interventions to choose from depending on the type of fall to add to the resident's fall plan of care. He stated this is how they evaluate what interventions worked and what did not. MDS B stated the risk for the resident for not having interventions in place on the plan of care would be that the resident would continue falling . In an interview on 05/16/24 at 01:43 PM, the DON stated all resident falls were reviewed quarterly by a fall committee. She stated each new falls was reviewed in the morning meeting, and interventions are communicated to the MDS coordinators for documentation on the care plan of interventions to prevent falls. Fall interventions would include things such as fall matts, low beds, physical therapy, or occupational therapy and should be documented on the care plan. The DON stated the risk to residents for not updating interventions would be continued falls, major injury head trauma, and brain bleeds . A record review of and undated facility policy and procedure titled Resident Falls Protocol reflected: The Care Plan will be updated with each new fall. 676386 Page 14 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #16) of 6 residents reviewed for pharmacy services. Residents Affected - Few The facility failed to monitor Resident #16 for side effects/adverse reactions for the use of Xarelto (an anticoagulant medication- blood thinner). These failures could place residents at risk of bruising, and bleeding. Findings included: Record review of undated face sheet reflected Resident #16 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #16 had the following diagnoses of acute respiratory failure, unspecified severe protein calorie malnutrition, chronic heart failure, and hypotension (low blood pressure). Record review of Resident #16s MDS dated [DATE] reflected she had a BIMs score of 14 indicating resident was cognitively intact. The MDS also reflected Resident #16 required assistance with dressing and grooming and used a manual wheelchair for mobility. Record review of Physicians Order Summary Report dated 05/15/24 for Resident #16 reflected an order for Xarelto (a blood thinner) to be given daily. Record review of the Order Summary also reflected there was no order for monitoring of the Xarelto. Record review of Medication Administration Record (MAR) for the month of April reflected resident had received Xarelto daily. The MAR also reflected there was no monitoring for side effects in place related to the use of the Xarelto. In an interview on 05/16/24 at 11:33 AM, RN A (charge nurse) stated residents are assessed for bleeding by visual assessments daily by the staff. If bruising or bleeding is noted nurses would document and notify the doctor. Nurses also complete weekly skin assessments and nurse aides would notify charge nurses of anything unusual that is found on the skin. There should be an order reflecting the need to monitor daily for bleeding, bruising, black tarry stools all the side effects from an anticoagulant. The risk to residents for not monitoring an anticoagulant for side effects would be low blood count, or unnoticed injuries . In an interview on 05/16/24 at 1:43 PM, the DON stated all residents taking an anticoagulant should be monitored for side effects. The daily documentation for monitoring would be noted on the MAR. The physicians' orders would reflect an order to monitor for side effects if a resident were on an anticoagulant. Side effects would include bruising, bleeding, blood in stools, or bleeding gums. The DON stated the ADON normally reviews orders for residents, and the DON spot check orders for accuracy at least 1 x weekly. The Pharmacist then reviews residents' orders monthly. The negative effects for the resident for not monitoring for side effects of the medication Xarelto would have included risk for bleeding bruising, side effects from medication. A record review of and undated facility policy and procedure titled Pharmacy and Procedures Purpose. Reflected 676386 Page 15 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0757 1. Level of Harm - Minimal harm or potential for actual harm Ensure that drugs are prescribed, administered, and handled in this facility in a manner that protects the safety and welfare of the patient. Residents Affected - Few 676386 Page 16 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0790 Provide routine and 24-hour emergency dental care for each resident. 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 assist residents in obtaining routine dental services for 2 of 6 (Resident #47 and Resident #107) residents reviewed for dental services. Residents Affected - Few The facility failed to assist Resident #47 and Resident #107 in obtaining dental services since their admission to the facility to assess for dental care needs. This deficient practice could affect residents by placing them at risk of not receiving necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being which could result in a decreased quality of life. Findings include: Record review of Resident #47's face sheet dated 5/16/2024 reflected diagnoses of nonrheumatic aortic stenosis (heart valve disease), mild cognitive impairment, ventricular premature depolarization (dysfunction of left ventricular), legal blindness, anemia (lack of red blood cells), disorientation and muscle weakness. Record review of admission MDS dated [DATE] for Resident #47 reflected a BIMS score of 13 which indicated no cognitive impairment at the time of the assessment. Further review of functional abilities reflected Resident #47 was independent for eating and performing oral hygiene. Review also reflected Resident #47 received a mechanically altered diet. MDS also reflected no weight loss of 5% in last month or 10% or more in last 6 months under the swallowing/nutritional status section for Resident #47. Review of care plan dated 3/11/2024 for Resident #47 reflected she had a potential nutritional risk due to poor dentition, chewing difficult that affected her ability to feed herself that included an intervention to serve a mechanical soft diet with ground meat texture. Review of social services initial assessment for Resident #47 dated 3/13/2024 reflected resident was to be put on list for routine services under social service referrals section which included dental, vision, psychological, podiatry and hearing services. Review of physician orders dated 03/07/2024 for Resident #47 reflected an order for a regular mechanical soft diet with ground meat texture. Review of nutrition assessment dated [DATE] indicated Resident #47 had broken, lose or carious teeth. Review of Resident #107's face sheet dated 5/16/2024 reflected diagnosis of acute respiratory failure (when there is not enough oxygen or too much carbon dioxide in your body), dysphagia (difficulty swallowing), anemia (lack of red blood cells), mild cognitive impairment, congestive heart failure (when the heart does not pump blood well enough into the body), essential hypertension (high blood pressure), and chronic obstructive pulmonary disease (a condition that constricts airways and causes difficulty breathing). Review of quarterly MDS dated [DATE] for Resident #107 reflected BIMS score of 8 which indicated 676386 Page 17 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0790 Level of Harm - Minimal harm or potential for actual harm moderate cognitive impairment. Review also reflected Resident #107 was independent for eating and required set up or clean up assistance with oral hygiene. Further review reflected Resident #107 had complaints of difficulty or pain with swallowing. Quarterly MDS also reflected no weight loss of 5% in last month or 10% or more in last 6 months in swallowing/nutritional status. Review reflected Resident #107 required a mechanically altered diet on admission through assessment date. Residents Affected - Few Review of Resident #107's care plan reflected she had a potential nutritional problem related to difficulty chewing. Review of social services initial assessment for Resident #107 dated 2/2/2024 reflected resident was to be put on list for routine services under social service referrals section which included dental, vision, psychological, podiatry and hearing services. Review of physician orders dated 1/27/2024 for Resident #107 reflected an order for a regular mechanical soft diet with ground meat texture. Review of nursing note dated 1/31/2024 reflected dietician requested diet change to mechanical soft due to resident not having bottom teeth. Review of dental list of residents who were seen for dental services for months of January 2024 through April 2024 indicated Resident #47 and Resident #107 were not listed as seen by the facility dental provider. During observation and interview on 05/14/2024 at 1:28 PM, Resident #47 was observed to have missing and broken teeth. Resident #47 stated she had a lot of missing teeth and several that are broken and stated she had not been seen by a dentist. Resident #47 stated she did not have issues eating. During observation and interview on 5/15/2024 at 9:44 AM, Resident #107 stated her top teeth started to become crooked and she asked to see a dentist previously. Resident #107 stated she has not seen a dentist. Resident #107 stated that she has some trouble eating items but usually her food is chopped. During an interview on 5/15/2024 at 3:24 PM, LVN B stated that would inform the social worker when a resident needed to see the dentist. LVN B stated that if a resident told her they wanted to see the dentist she would tell the social worker. LVN B stated if a resident stated something bothered them in their mouth, she would assess the resident and may contact the doctor or depending on the outcome of the assessment let the social worker know if the resident needed to see a dentist. During an interview on 05/15/2024 at 3:41 PM, CNA A stated that when she provided oral care daily to residents, she looked for inflamed gums. CNA A stated that she also looked if the resident had gums there were irritated, swollen or if they bled during oral care. She stated she would report any changes or concerns to the nurse and would report broken teeth to the nurse. During an interview on 05/16/2025 at 3:41 PM, LVN A stated that she was able to know if a resident needed to see a dentist if they complained their mouth hurts. LVN A stated she looked for swelling or bleeding and she was aware of any mouth discomfort residents had. She stated that she would assess the resident and was aware of any discomfort when she provided oral care. She stated that she would let the social worker know when a resident needed to see the dentist so they can be put on a list if it is something that could wait. She stated that she would also inform the doctor so the resident 676386 Page 18 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0790 could be sent out sooner. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/16/2024 at 10:43 AM, CNA B stated that she looked to see if a resident's intake had declined to determine if she thought a resident needed to see the dentist. CNA B stated that during oral care she also looked for any discomfort, if the resident complained of pain or if their face was swollen and stated she would report any of these changes to the nurse. Residents Affected - Few During an interview on 5/16/2024 at 11:29 AM, the SW stated dental services are offered to residents upon admission. She stated that the nurse will let her know if there is any kind of pain and then the referral would be sent. She stated that most residents use the provide that comes to the facility. The SW stated that once the resident is on the list to be seen, the dental provide reaches out to the resident and their family twice a year to ensure they want to remain on the list. The SW sated that the dentist comes twice a month, but if the resident is having pain they can be seen sooner. The SW stated that if residents are having trouble chewing, they can also be seen because of this. She stated that Resident #107 is on the list to be seen but is on hold because she was on skilled services. She stated that Resident #107 is not able to be seen while she is on skilled services. She stated that she does not know if Resident #47 is on the list. During an interview on 05/16/2024 at 1:00 PM, the SW stated a referral was not sent for Resident #47 due to the resident being on skilled services. The SW stated the resident is not able to be seen by the dentist due to being on skilled services. During an interview on 5/16/2021 at 2:28 PM, the DON stated that dental/oral services are carried out by referring the resident to a dentist if anyone complains of dental pain or if anything is noted by nursing staff. The DON stated that occasionally residents prefer to see an outside dentist. The DON stated that depending on when the referral was sent is when the resident would be seen by the dentist. She stated that the process of referring a resident to the dentist is that nursing that notifies the social worker if there are dental concerns such as a tooth ache or broken tooth. The DON stated that nursing staff assess if the resident needs a referral or if they need an emergency visit prior to the next scheduled dentist visit. The DON stated that oral care is expected every day. She stated that the facility provides one time use toothbrushes with premeasured tooth paste and denture supplies. During an interview on 05/16/2024 at 2:33 PM, the ADM stated that the social worker is responsible for setting up dental services for residents. The ADM stated that residents should be referred to a dentist within 3 days of after requested or an identified need. The ADM stated that normally the SW refers the resident as soon as she finds out about it and emails the dentist they are contracted with. When asked how the facility ensures that a dentist is available for residents, the ADM stated that she ensures they have a contact dentist and if a need arises the facility obtains another dentist. The ADM stated that a resident is able to see a dentist in the community if they want. When asked if a resident being on skilled services should prevent them from being able to see a dentist the ADM stated no. Review of undated facility policy titled Dental Policy reflected that residents have a choice of using an in-house dentist or they may go to a dentist of their choice. The policy also reflected that upon admission through the social services initial assessment residents are asked if they are having any trouble chew or pain, and if so, they are referred to the dentist. If a resident reports a lost or broken tooth nursing staff notified social service and a dental referral is made. If there is pain or an emergency dental need, out in-house provider is available via phone and in-person within 3 676386 Page 19 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0790 Level of Harm - Minimal harm or potential for actual harm days. The facility will assist the resident if necessary or requested in making a prompt referral to a dental provider within 3 business days. If the referral cannot occur within 3 business days, the facility, must provide documentation as to why the delay occurred. Residents Affected - Few 676386 Page 20 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

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 in 1 of 1 kitchen reviewed for dietary services. Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 05/14/2024 at 08:37 AM, the following was observed in the walk-in freezer. a bag appeared to be opened French fries in a clear plastic bag with no label or no dates documented, and a bag appeared to be opened meat patties in a clear plastic bag with no label or no dates documented. Interview with [NAME] A on 05/14/24 at 9:05 AM, [NAME] A stated that it would be the cook or the assist cook's responsible to label and date items that they had opened for a meal. [NAME] A stated she had not opened the unlabeled and undated items and did not know the items was not labeled and dated. [NAME] A stated if food was not labeled or dated then residents could get sick from the unlabeled and undated food. Interview with [NAME] B on 05/14/24 at 9:15 AM, [NAME] B stated that it would be the cook or assist cook is responsible to label and date items that they have opened for a meal. [NAME] B stated if an item in the freezer was not labeled or dated then the items could be old. [NAME] B stated if the items were old that would put the residents at risk of getting sick. Interview with the Dietary Manager on 05/14/24 at 9:25 AM, the DM stated the unlabeled and undated items were French fries and chicken patties. The DM stated the cook and assistant cooks were responsible for labeling or dating items that they have opened. The DM stated that all opened items should be labeled and dated. The DM stated food items could be old if not appropriately labeled with a received, opened, and used by dates. The DM stated if food was outdated then that would possibly put residents at risk for getting sick. Record review of the facility's Food Storage policy, dated 2005, reflected Policy: Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperate and by methods designed to prevent contamination. Procedures 13. Leftover food is stored in covered container or wrapped carefully and securely. Each item is clearly labeled and dated before refrigerated. Leftover food is used within 3 days or discarded. A record review of the FDA's 2022 Food Code reflected the following: 676386 Page 21 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0812 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Level of Harm - Minimal harm or potential for actual harm (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-TOEAT, 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. Residents Affected - Some (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: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; 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. 676386 Page 22 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

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 establish and 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 infection for 1 of 5 residents (Resident #61) reviewed for infection. Residents Affected - Few The facility failed to ensure LVN A performed hand hygiene prior to medication administration for Resident # 61. The facility failed to ensure LVN A performed hand hygiene after glove use during medication administration for Resident #61. The facility failed to ensure LVN A performed cleaning and disinfecting of blood pressure cuff after use on Resident #61. These failures could lead to the spread of infection to residents, residents illness, and /or resident distress. Findings include: Record review of the admission sheet dated 5/17/24 for Resident #61, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included T11-T12 Vertebra fracture (Spinal vertebra fracture), Schizoaffective Disorder Bipolar type (A rare mental illness that occur when someone experiences both schizophrenia and bipolar disorder), Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat.), Acute Respiratory Failure (is a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide.), Type 2 Diabetes w/ other Circulatory Complications i.e. Foot Ulcer (A condition results from insufficient production of insulin, causing high blood sugar). Record review of Resident #61's Quarterly MDS, dated [DATE], revealed he had a BIMS score of 12 out of 15, indicative of moderately impaired cognitively. Observation on 05/15/24 at 9:15 AM, revealed LVN A provided Resident #61 with medication administration. LVN A failed to perform hand hygiene prior to starting medication administration for Resident #61. During review of Resident #61 medications LVN A determined Resident #61 required a blood pressure reading prior to administration of medication. LVN A donned gloves and took Resident #61's blood pressure. After completing blood pressure reading LVN A doffed gloves and failed to complete hand hygiene prior to continuing medication administration for Resident # 61. Upon completion of medication administration LVN A failed to complete disinfection of blood pressure cuff used on Resident #61. In an interview on 05/16/24 at 2:37 PM, the DON said during medication administration that hand hygiene is expected to be performed between residents, when hands are visibly soiled, after glove use, and after medications are touched. The DON further said during medication administration blood pressure cuff disinfection/sanitization is to be performed after each use between each resident. The DON said training for medication administration, hand hygiene, and infection control are done yearly as a skills check-off and after incidents have occurred. 676386 Page 23 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0880 Level of Harm - Minimal harm or potential for actual harm Record review of facility's Medication Administration policy (undated) revealed All Licensed nurses will administer medications as ordered by physician, All Licensed nurses will follow the 6 rights of medication administration. Licensed nurses will also: 2. Administer medications and treatments and perform procedures safely. Residents Affected - Few Record review of facility's Handwashing/Hand Hygiene policy (undated) revealed under Responsibility: All Nursing Staff Purpose: 1. To thoroughly cleanse/sanitize the hands. 2. To control infection through medical asepsis 3. To reduce transmission of organisms from resident to resident 4. To reduce transmission of organisms from staff to resident 5. To reduce transmission of organisms from resident to staff General Instructions: Hands should be thoroughly washed / sanitized before and after providing care. Hands should be thoroughly washed / sanitized after changing gloves. Proper hand hygiene must be always followed. Equipment: 1. Soap 2. Comfortably warm water 3. Paper towels 4. Alcohol based hand sanitizer Procedure: Soap and water technique 1. Stand so clothing does not touch sink. 2. Place hands under water. 3. 676386 Page 24 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0880 Apply soap and work up lather. Using friction (rubbing), wash entire surface of hands for at least 20 seconds. Wash hands thoroughly, including wrists, palms, back of hands, and under the fingernails. Level of Harm - Minimal harm or potential for actual harm 4. Residents Affected - Few Clean soil from under fingernails. 5. With hands below wrists, rinse the soap from your hands. Do not splash water onto clothing. Do not allow hands to touch sink. 6. Dry hands completely with a clean paper towel. 7. Using paper towel to turn off water. Discard paper towel in trash can. Alcohol based hand sanitizer technique 8. Apply sanitizer to the palm of one hand. 9. Rub hands together. 10. Rub sanitizer over all surfaces of hands and fingers until hands are dry. Remember: If soap and water are not available, use alcohol-based hand sanitizer. If visible soil is present on the hands, wash hands with soap and water. Record review of facility's Cleaning, Disinfecting, and Sterilization policy dated 2009 revealed under Purpose: To provide supplies and equipment that are adequately cleaned, disinfected, or sterilized. Policy: I. 676386 Page 25 of 26 676386 05/17/2024 West Rest Haven 503 Meadow Drive West, TX 76691

F 0880 Cleaning: Level of Harm - Minimal harm or potential for actual harm A. Residents Affected - Few Supplies and equipment will be cleaned immediately after use. Gross blood, secretions, and debris will be removed as soon as possible. Cleaning may be done in the resident's room or the soiled utility room. II. Disinfection/Sterilization: A. Resident care equipment that enters normally sterile tissue or the vascular system, or through which blood flows, will be sterile. B. Respiratory therapy equipment that touches mucous membranes should be subjected to sterilization before each use; if not feasible, it will receive high-level disinfection. III. Classification of Devices, Processes, and Germicidal Products Noncritical (touches intact skin): low-level disinfection using hospital disinfectant without label claim for tuberculocidal activity Record review of LVN A's personnel file revealed a hire date of 01/18/16. Initial orientation check-off including hand hygiene, universal precautions, and infection control dated 01/18/16. Record review of LVN A's annual competency skills check-off dated 05/07/24 revealed a check of satisfactory for hand hygiene, universal precautions, and infection control practices. 676386 Page 26 of 26