Health inspection·July 21, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for two (Cart 1 and Cart) of two medication carts. The facility failed to lock Cart 1 and Cart 2 carts leaving all medications on the carts accessible. These failures could affect all resident by placing them at risk for possible drug diversions. Findings included: Observation on 07/19/23 at 9:50 AM revealed cart 1 left unattended and unlocked for approximately 10 minutes. There were no staff members near the medication cart. Observation on 07/19/23 at 11:11 AM revealed LVN A obtained medication from Cart 2 and walked to the dining area to pass the medication while leaving med cart 2 unlock with no other staff nearby. Interview on 07/19/23 at 10:10 am with CMA A revealed she was not sure who was last using Cart 1 and that she thought it was the nurse's cart. CMA A continued working and did not lock med cart 1. Interview on 07/19/23 at 11:13 AM with LVN A revealed he was aware that he should not have walked away from Cart 2 without locking it. LVN A stated there was no reason he left the cart unlocked and stated the risk of leaving the cart unlocked would be someone would have access to the medication. The med cart contained resident PRN medication and ointment. Interview on 07/20/23 at 2:00PM with the ADON revealed her expectation is for med carts to always be locked when unattended. The ADON stated a in services was completed about two weeks ago regarding medication administration. The ADON stated the risk of leaving the medication cart unlocked would be residents could take medication or other items from the nurse's cart. The ADON stated nurse carts contain PRN medication and med aid carts contain routine medication. Review of policy Policy/ procedure- Nursing clinical care and treatment policy number NCMA 19 dated 11/2022 revealed It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed Page 1 of 5 676413 676413 07/21/2023 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0761 nursing personnel, pharmacy, or staff members lawfully authorized to administer medications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 676413 Page 2 of 5 676413 07/21/2023 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

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 reviews, 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 two (Resident #1 and Resident #2) of nine residents and two (Housekeeper A and Floor Tech A) of three staff reviewed for infection control . Residents Affected - Some The facility failed to ensure staff properly donned and doffed PPE when entering or leaving the COVID hot hall. The facility failed to cohort residents based upon their COVID-19 status. Resident #2 who was COVID-19 positive and Resident #1 who was COVID-19 negative were not separated. These failures placed residents at risk of exposure to COVID-19, which could result in cross-contamination and infection. Findings included: Review of the electronic face sheet dated 07/19/23 for Resident #1 revealed an 83- year - old female admitted to the facility 01/16/22 with diagnoses that included chronic kidney disease, pneumonia, Alzheimer's, hypothyroidism, essential hypertension. Review of Resident #1's MDS dated [DATE] revealed the BIMS score was not completed. Resident #1 was tested for COVID on 7/19/23 and revealed negative results. Review of the electronic face sheet dated 07/19/23 for Resident #2 revealed an 81- year- old female admitted to the facility on [DATE] with diagnoses that included dementia, hypertension (high blood pressure) and dysthymic disorder (a milder, but long-lasting form of depression). Review of Resident #3's MDS dated [DATE] the BIMS score was not completed. Resident was tested for COVID on 07/19/23 and revealed positive results. Observation on 07/19/23 at 10:10 AM revealed Housekeeper A entered the 600 hall which had both the double doors closed with signage on the door that indicated do not enter without seeing a nurse. The double doors contained signage detailing how to donn and doff PPE. Outside the double doors was a bin which contained all PPE needed to enter the hall. Housekeeper A entered the 600-hall without a gown, face shield or gloves. Housekeeper A was called out of the hot hall by Housekeeping Supervisor and education on proper PPE needed. Interview on 07/19/23 at 10:15 AM with Housekeeping Supervisor revealed she was not sure why Housekeeper A was entering the COVID hot hall without full PPE. The Housekeeping Supervisor stated all staff was trained on donning and doffing PPE on 07/16/23. Interview on 07/19/23 at 10:30AM with Housekeeper A revealed she barely spoke English and did not provide an explanation as to why she did not put on PPE before entering the COVID hot hall. 676413 Page 3 of 5 676413 07/21/2023 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0880 Level of Harm - Minimal harm or potential for actual harm Observation and interview on 07/19/23 at 10:20 AM with Resident #1 in her room revealed Resident #1 did not have a mask on however she was provided a mask. Resident #1 stated Resident #2 was in the restroom and had tested positive for COVID-19. Resident #1 revealed she tested negative for COVID-19. Resident #1 stated she and her roommate had been tested that morning however she did not know when her roommate would be moved out of the room. Residents Affected - Some Interview on 07/19/23 at 10:23 AM with Resident #2 revealed she tested positive for COVID-19 on 07/19/23 and was informed that she would be moved to the hot hall however she was not sure how long it would take. Observation on 07/19/23 at 10:49 AM revealed Floor Tech A exiting the COVID hot hall without removing his gown, gloves, or face mask. Floor Tech A slid a mattress from the COVID hot hall and took it near the dining room before being stopped by the Housekeeping Supervisor and was asked to remove his PPE. Floor Tech A spoke limited English however was directed by the Housekeeping Supervisor who was Spanish speaking to remove the PPE. Once Floor Tech A removed his PPE, he proceeded to take the mattress to another room which was being prepared for a new admit. The Housekeeping Supervisor stated she directed Floor Tech A to remove the mattress from the COVID hot hall. The Housekeeping Supervisor stated Floor Tech A received training on donning and doffing PPE on 07/16/23. The Housekeeping Supervisor stated Floor Tech A was nervous due to state being in the building. Review of the signage on 07/19/23 at 10:00AM on the closed double doors of COVID hot hall reflected, Sequence for putting on personal protective equipment (PPE) and How to safety removed personal protective equipment. Interview LVN B on 07/19/23 at 11:00 AM revealed he had worked in the facility for about 2 months. He stated when residents were positive for COVID-19 they were transported with a mask on immediatley to the COVID hot hall which was the 600 hall. LVN B stated when there was a COVID-19 positive resident and COVID-19 negative resident in the same room the COVID-19 negative resident was removed from the room then the COVID-19 positive resident was moved to the hot hall. LVN B stated the COVID-19 negative resident would not return to the room until it was deep cleaned. LVN B was responsible for relocating Resident #2 from the room however at the time of the interview stated he had no other residents to transport to the COVID hot hall. Interview on 07/19/23 at 11:25 AM with the ADON revealed she had worked in her current position since February 2023. The ADON revealed upon testing a resident and receiving a positive COVID-19 result, the COVID-19 positive resident should be immediately moved to the hot hall. The ADON stated if there was a COVID-19 negative roommate, that roommate must be removed from the room to allow the room to be deep cleaned. The ADON stated the COVID-19 outbreak began on 07/16/23 with another resident and stated there was testing complete on 07/19/23 due to there being a outbreak at the facility. The facility conducted additional testing on 07/19/23 which revealed 3 additional residents were COVID-19 positive. The ADON stated staff were in-serviced on proper way to put on and take off PPE on 07/16/23 and 07/17/23. The ADON stated nothing should be removed from the hot hall. Interview on 07/19/23 at 12:00PM with the Administrator revealed the housekeeping staff were trained on donning and doffing PPE on 07/16/23 and 07/17/23 along with the rest of the facility staff. The Administrator stated staff were aware of proper procedures of donning and doffing PPE. The Administrator stated staff should not have remove any items from the hot hall and placed them in other 676413 Page 4 of 5 676413 07/21/2023 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some rooms. The Administrator stated upon testing residents for COVID-19, once a positive resident was identified they should be immediately removed from the room. She stated if there was a roommate that was COVID-19 negative, that resident should have been removed to allow deep cleaning of the room. Interview on 07/19/23 at 12:05 PM with Clinical Resources revealed the DON was the infection control specialist however she was out of the country. Clinical Resources stated she also assisted the DON regarding infection control by assisting with training staff. She stated only staff that worked on the hot hall are required to wear an N95 mask. Clinical Resources stated once a resident is identified to be COVID-19 positive, that resident should be moved immediatley. Clinical Resources stated the COVID-19 negative resident should be removed from the room to allow the room to be deep cleaned and sanitized. She stated all facility staff were in-serviced on PPE donning and doffing on 07/16/23 when the outbreak began. Clinical Resources stated staff should not be removing any items from the hot hall and placing them in other rooms. The Clinical Resources stated staff should be disposing of PPE inside the door of the hot hall prior to exiting the hall. Clinical Resources stated the risk of not practicing proper infection control would be the facility would have an outbreak. Review of the facility policy Infection Control 483.80, dated 6-2021 reviewed 10-2022 revealed, The facility personnel will conduct themselves and provide care in a way that minimizes spread of infection. Review of facility policy COVID-19 Testing 483.80 infection control, dated 09-2020 revised 10-2022, revealed It is the policy of this facility to provide or obtain laboratory testing services for residents to assist in the identification and management of SARS- COv-2(COVID-19) infections and /or outbreaks. Testing will be performed according to current local/ state health departments and Centers for Disease Control and Prevention guidelines. 676413 Page 5 of 5