Health inspection·June 15, 2023

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 observation, interviews, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #50, #204) of 14 residents observed for call light placement. Residents Affected - Few The facility failed to ensure Residents #50 and #204 ' s call lights were within their reach. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Resident #50 Record review of Resident #50 ' s face sheet dated 06/14/2023 documented he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #50 ' s History and Physical dated 05/23/2023 documented he had diagnoses including a stroke, and left hemiplegia (paralysis of the left side of the body). It was documented on the History and Physical that the resident was able to move his right arm and leg when asked to do so. Record review of Resident #50 ' s admission MDS dated [DATE] documented the BIMS interview was not completed because the resident was rarely understood. The MDS indicated staff members said he had short- and long-term memory problems. The MDS indicated he had no symptomatic behaviors. The MDS indicated he was totally dependent on two staff members to move around in bed, transfer between surfaces, dressing, eating, toileting and personal hygiene. Record review of Resident #50 ' s Interim Care Plan dated 05/23/2023 documented the resident was able to understand staff members. He was totally dependent on others for bed mobility, transfer between surfaces, dressing, eating, toileting and personal hygiene. The Interim Care Plan did not include any information regarding call light placement or availability. In observation on 06/13/23 at 10:23 AM, Resident #50 was lying in bed with his eyes open and did not respond to requests to state his name or inquiries about how he was doing. His call light was observed beyond his reach in the opened nightstand drawer. His tube feeding pump and oxygen concentrator were between him and the nightstand where his call light had been placed. In an interview and observation on 06/13/23 at 10:23 AM, CNA F said Resident #50 ' s came to the Page 1 of 34 676457 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident ' s room and saw the call light placement. She said the call light was in the resident ' s nightstand drawer and not where he could reach it because he was confused and did not know how to use it. She said that CNAs and nurses were responsible for making sure residents had their call lights within reach, but that Resident #50 did not have his call light within reach because he did not use it. In an interview and observation on 06/13/23 at 10:25 AM, LVN E observed the placement of Resident #50 ' s call light. She said Resident #50 did not have his call light within reach because he tended to pull things like his sheets and his urinary catheter. She said staff tried to keep things away from his right side because he lifted his right hand, would pull on things with his right hand and would throw things with his right hand, so they did not put his call light where he could reach it. She said that residents were supposed to have a call light so they could call staff for help, and if they did not have one, they would not be able to get help if needed. Resident #204 Record review of Resident #204 ' s face sheet dated 06/15/23 revealed admission on [DATE] to the facility. Record review of Resident #204 ' s history and physical dated 05/31/23 revealed a [AGE] year-old male diagnosed with dementia acute nontraumatic intraparenchymal hemorrhage (damage to cerebral blood vessels which burst and bleed into the brain), and acute left frontoparietal subdural hematoma (a clot of blood that develops between the surface of the brain ). Record review of Resident #204 ' s admission MDS dated [DATE] revealed a brief interview mental status (an interview to identify alertness, orientation, and recall) score of 1. Resident ' s ADLs require extensive assistance for bed mobility, dressing, and personal hygiene and was total dependence for transfer, eating, toilet use, bathing. Resident #204 ' s diagnosed with stroke, traumatic brain injury, and respiratory failure. Record review of Resident #204 ' s Care Plan dated 06/11/23 revealed Resident #204 ' s had the potential for injury due to being a fall risk. Instruct resident to call for help before getting out chair, demonstrate the use of the call light for resident, keep call light in reach at all times, visible resident and the resident was informed of its location and use. Observation on 06/13/23 at 9:35 AM, the call light was not within reach of Resident #204. It was on his right-side bed on the floor. Observation and Interview on 06/13/23 at 9:38 AM, The RN D stated Resident #240 ' s call light was lying on floor. The RN D stated Resident #240 needed to have the call light within reach. The RN D stated residents need the call lights within reach in case they need to call the nurses for anything. RN D stated Resident #240 not having his call light within reach could be a risk if he were to get up and have a fall. Interview on 06/15/23 at 9:49 AM, The LVN E stated call lights are to notify the nursing staff of anything by the residents. The LVN E stated call lights need to be within reach of a resident to be able to call for help or anything. The LVN E stated everybody was responsible for ensuring call lights are within reach of the residents. 676457 Page 2 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/15/23 at 3:53 PM, the DON stated call lights are used by the resident to call for assistance. The DON stated if the resident was dependent the resident would need to have the call light within reach. The DON stated if the call light was not within reach, then the residents would not be able to call for assistance. The DON stated staff are trained to place call lights within reach of all residents. Record review of the facility ' s policy, Call System, residents dated 09/2022 revealed each resident was provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 676457 Page 3 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure that staff may attend resident group meetings only at the respective group's invitation for one of one resident group reviewed for staff attendance at group meetings by invitation. Residents Affected - Few The facility failed to inform the resident council that they could hold council meetings without staff members present. This failure could put residents at risk of reduced opportunities to express their concerns. Findings included: In a confidential group interview on 06/14/2023 at 10:30 AM, three residents who attended resident council meetings regularly stated that they were unaware they could hold meetings without facility staff members present. Residents attending the confidential group interview said they had not raised any concerns about the facility during Resident Council meetings. In an interview on 06/15/23 at 01:34 PM the Activity Director said the facility did not offer Resident Council the option to meet without staff members present. The Activities Director stated she did not know it was the Resident Council ' s right to meet without staff members present. She said the advantage to residents of not having staff present during their meetings was that residents would feel more confident expressing themselves, so they would be at risk of not expressing their concerns with staff members present. The Activities Director said she also completed the minutes for the Resident Council meetings. Record review of Resident Council Minutes for 01/16/2023, 03/22/2023, and 05/12/2023 revealed no staff members names in the space labeled Staff Members Invited by Resident Council and in Attendance. Further review of minutes for Resident Council meetings on 02/20/22 and 04/25/2023 revealed staff members were in attendance. Record review of the facility policy Resident Rights revised 12/2016 documented in part that residents have the right to privacy and confidentiality, 676457 Page 4 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 1 of 6 (Resident #259) residents reviewed for telephone use. Residents Affected - Few The facility failed to provide a place for Resident #259 could make telephone calls without being overhead. This failure could place residents at risk of conversations being overheard and privacy rights not being respected. The findings included: Record review of Resident # 259's face sheet dated 6/14/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident # 259's local hospital history and physical dated 5/22/23 revealed diagnoses of major depressive disorder. Record review of Resident # 259's MDS admission assessment dated [DATE] not yet completed revealed a BIMS score of 15, he was cognitively intact. Observation and interview on 6/14/23 at 2:32 PM Resident #259 was in wheelchair at nurse's station using phone. Staff were observed passing by nurse's station. Resident #259 stated he did not feel comfortable using the phone by the nurse's station because there was no privacy. Resident #259 did not know of any other place where he could use the telephone. Resident #259 stated staff did not offer to use a different phone that provided privacy and had only ever seen other residents use the phone by nurse ' s station. Observation on 6/14/23 at 3:30 PM Resident #259 was by nurses station making a telephone call and staff were passing by at lengths reach. Interview on 06/14/23 at 3:34 PM LVN G stated the staff dial for the residents if they wanted to make a phone call there at the nursing station. LVN G stated the facility does not have any privacy rooms for the residents to use when making a phone call. LVN G stated she believed that there was no privacy for the residents who used phone at the nurses' station because people constantly passed by the nurses ' station. LVN G stated if the residents ask to go to the activity's office, then they will take them to use the phone. LVN G stated they have not offered the room for privacy during phone calls, and she believed that the residents are unaware that they may use the activities office for privacy when using the phone. Interview on 06/14/23 at 3:40 PM RN H stated residents could use the phone in the reception area and in the nurse's station. RN H stated residents may use the telephone at the nursing station if they feel comfortable. RN H did not answer the question regarding if the resident feels comfortable or not. Interview on 06/15/23 at 3:53 PM the DON stated they offer their cell phones and the phones at the 676457 Page 5 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0576 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse's station to residents. DON stated if residents do not feel comfortable, they may request privacy. DON stated staff are trained in providing privacy for residents when using the telephone. Record review of the facility ' s Telephones policy dated May 2017 revealed Residents shall have easy access to telephones. 1. Designated telephones are available to residents to make and received private telephone calls. 676457 Page 6 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 6 (Resident #259 and Resident #34) residents reviewed for abuse. The facility failed to report alleged verbal abuse for Resident #259 to State Agency. The facility failed to report alleged financial exploitation for Resident #34 to State Agency. These failures could affect residents by placing them at risk of abuse if the reportable allegations are not reported in time after they are alleged. Resident #259 Record review of Resident # 259's face sheet dated 6/14/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident # 259's local hospital history and physical dated 5/22/23 revealed diagnoses of major depressive disorder. Record review of Resident # 259's MDS admission assessment dated [DATE] not yet completed revealed a BIMS score of 15, he was cognitively intact. Record review of complaint/ grievance report dated 6/9/23 for Resident #259 revealed complaint was communicated to Administrator and concerns detail was being verbally abused by staff. Describe concern in detail revealed nurse called him a drug dealer or drug addict. Findings of investigation revealed nurse denied calling Resident #259 a drug dealer or drug addict. Results of actions taken section revealed talked with Resident #259 related regarding nurse denied calling him a drug dealer and/or drug addict. Reportable to state agency section revealed no was marked off. Interview on 6/13/23 at 10:23 AM Resident # 259 was alert and oriented to person, place, time, and event. Resident # 259 stated he had a confrontation with LVN A last Friday (6/9/23). Resident # 259 stated he had requested pain medication from LVN A, and the pain medication was denied by LVN A Resident # 259 stated LVN A had called him a drug addict and felt verbally abused. Resident # 259 stated he reported this incident to the Administrator the day of the incident but could recall a timeframe. Interview on 6/14/23 at 10:31 AM, the Administrator in Training stated Resident #259 approached him Friday 6/9/23 and voiced an interaction he had with LVN A where he had called him a drug addict or drug dealer. The Administrator in Training stated he could not remember if he had mentioned either drug addict or drug dealer and included both in grievance. The Administrator in Training stated he followed up with LVN A and was notified that Resident #259 was the one who was verbally abusive to staff and denied calling Resident #259 a drug addict or drug dealer. The Administrator in Training stated after his investigation was completed, he determined the allegation was unsubstantiated due to inconsistencies from LVN A and Resident #259 details during interaction of verbal abuse in question. 676457 Page 7 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0609 Level of Harm - Minimal harm or potential for actual harm The Administrator in Training stated he did not report to the State Agency due to his investigation being unsubstantiated. The Administrator in Training referred to Abuse policy and stated he did not refer to federal requirements for reporting allegations within timeframes. Resident #34 Residents Affected - Few Record review of Resident #34 ' s face sheet dated 6/15/23 revealed a [AGE] year-old male who was admitted on [DATE] and discharged on 6/12/23. Record review of Resident #34 ' s history and physical dated 1/19/23 revealed diagnoses of residual aphasia (unable to formulate language because of damage to specific brain regions )and right hemiplegia( weakness to one entire side if the body). Record review of Resident #34 ' s MDS quarterly assessment dated [DATE] revealed Resident #34 was moderately cognitive impaired. Record review of Resident #34 ' s social services progress noted dated 3/22/23 revealed SW received Guardianship documents from Probate court a Temporary Guardian. Temporary Guardian instructed all visitors for Resident #34 be supervised. Interview on 6/15/23 at 9:26 AM, the SW stated Resident #34 was admitted on [DATE]. The SW stated Resident #34 was appointed a Temporary Guardian back in March 2023 related to financial concerns. The SW stated Resident #34 had FBI and APS investigations in the past related to Business Partners POA and financial concerns The SW stated back in March 2023, the Receptionist was sitting in one of the supervised visits and notified her that visitor was at bedside and showing what appeared to be properties via cell phone and was asking Resident #34 questions like what about this one? followed by questions in the lines of want to get rid or sell. The SW stated when the Receptionist reported this to her, she immediately reported the incident to Resident #34 temporary Guardian. Interview on 6/15/23 at 2:30 PM, Receptionist stated she could not recall the date or time when she sat in during Resident #34 supervised visit. The Receptionist stated during the visit she was sitting on a bedside chair and Resident #34 was laying down in bed, his back facing her. The Receptionist stated after some short talk between Resident #34 and the Visitor, Visitor showed Resident #34 his phone and started asking questions like what about this one? Do you want to get rid of it or sell it. The Receptionist stated she could not remember exactly what term was used when the Visitor was asking those questions. The Receptionist stated Resident #34 was not verbal and could tell he was attempting to speak but could not say a word. The Receptionist stated she was concerned due to the history of financial issues, and she decided to report this incident to SW. The Receptionist stated she was concerned of financial exploitation due to the questions that were being asked and Resident #34 not being able to answer. Interview on 6/15/23 at 2:35 PM, SW stated when she received the report from The Receptionist, she immediately reported the observed incident to Resident #34 Temporary Guardian due to concerns of financial exploitation. SW stated she did not feel she needed to report this incident to State Agency due to Resident #34 financial concerns being investigated by APS, FBI and ongoing court hearings. SW stated she received abuse and neglect training at least once a year. The SW stated she had been trained to report any type of abuse I.e. verbal, physical, sexual and financial exploitation to State Agency. The SW stated she reported concern to DON and AIT. 676457 Page 8 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 6/15/23 at 2:52 PM, the Administrator in Training stated he was aware of Resident #34 financial situation. Administrator in Training denied receiving reports of alleged financial exploitation for Resident #34. Administrator in Training stated what was reported to him back in March was that The Receptionist did not feel comfortable sitting in supervised visits due to the incident she had witnessed. The Administrator in Training stated if he would have received report or concern of witnessed financial exploitation, he would have reported the incident to the State Agency. Administrator in Training stated SW did not follow chain of command and did not report concern to him. Interview on 6/15/23 at 3:09 PM Resident #34 was hard to understand. Resident #34 nodded yes to understanding questions and would attempt to answer. Resident #34 was extremely hard to understand due to aphasia (a person is unable to comprehend or unable to formulate language because of damage to specific brain regions). Resident #34 was given a pen and paper and attempted to write but handwriting was not legible. Interview on 6/15/23 at 1:42 PM telephone call was placed to Resident #34 Temporary Guardian, and voicemail was left. Call was not returned by time of exit. Interview on 6/15/23 at 4:06 PM Administrator stated staff received abuse and neglect training upon hire and annually. Administrator stated the Administrator in training and himself were the abuse coordinators. Administrator stated he was notified by General Manager of Resident #259 and LVN A interaction last week related to confrontation between them. The administrator stated no one referred to the incident as verbal abuse until State Agency was in the building. The Administrator stated he was notified by the General Manager of Receptionist witnessed incident with visitor and Resident #34 but was relayed to him that she was uncomfortable. The Administrator stated no one called the incident a financial exploitation concern until the State Agency was in the building. The Administrator stated any alleged verbal, physical, sexual, exploitation concerns were required to be reported to the State Agency. Record review of the facility ' s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021 revealed Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. 9: Investigate and report any allegations within timeframes required by federal requirements. 676457 Page 9 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission for 1 of 6 residents (Resident #11) reviewed for baseline care plan. Resident #11 did not have a baseline care plan that addressed her oxygen use. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings included: Record review of Resident #11's face sheet dated 06/15/23 revealed admission on [DATE] and readmission on [DATE], and readmission on [DATE] to the facility. Record review of Resident #11's history and physical dated 05/09/23 revealed an [AGE] year-old female diagnosed with Peripheral arterial disease (happens when there is a narrowing of the blood vessels outside of your heart) and diabetes. Record review of Resident #11's MDS dated [DATE] revealed a diagnosis of debility (physical weakness, especially as a result of illness), cardiorespiratory conditions, diabetes mellitus, respiratory failure, and acute respiratory failure with hypoxia. (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood). Further review revealed the resident was on oxygen therapy. Record review of Resident #11's baseline care plan dated 06/15/23 revealed there was no documentation of care for oxygen use for Resident #11 in the baseline care plan. Record review of Resident #11's order recap dated 06/15/22 revealed order date 05/09/23 oxygen at 1 liter per minute via nasal cannula continuous. Observation on 06/13/23 at 10:47 AM revealed Resident #11 had an oxygen tank in her room and a concentrator in the restroom. Neither the tank or the concentrator was in use. Interview on 06/15/23 at 10:23 AM MDS Nurse C stated oxygen use was not in Resident #11's baseline care plan. MDS Nurse C stated oxygen use needed to be in Resident #11's baseline care plan within 48 hours of admission. Interview on 06/15/23 at 11:19 AM MDS Nurse B stated in Resident #11's baseline care plan there was no use of oxygen document. MDS Nurse B stated she was responsible for the baseline care plans and did not know why oxygen was not in Resident #11's baseline care plan. MDS Nurse B stated Resident #11 not having oxygen use in her care plan was not a risk to her because she had an order. MDS Nurse B stated if there was no order then there would be a risk to the resident because the oxygen was not care planed. MDS Nurse B stated it was required to have the oxygen use in the baseline care plan. 676457 Page 10 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's policy care plans - baseline dated 2001 revealed a baseline plan of care to meet the resident's immediate health and safety needs would be developed for each resident within forty-eight (48) hours of admission. The baseline care plan would include instructions needed to provide effective, person-centered care of the resident that met professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including physician orders and therapy services. 676457 Page 11 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

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 develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Resident #10 & Resident #11) reviewed for comprehensive care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #10s urinary foley catheter and Resident #11s oxygen use. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Resident #10 Record review of Resident #10's face sheet dated 6/15/23 revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #10's history and physical dated 5/3/23 revealed a diagnosis of dementia and retention of urine. Record review of Resident #10's MDS significant change in status assessment dated [DATE] revealed Resident #10 was severely cognitive impaired. Sectional H revealed Resident #10 had an indwelling catheter. Record review of Resident #10's baseline care plan dated 5/23/23 bladder function revealed Resident #10 had catheter. Observation and interview on 6/13/23 at 9:17 AM, Resident #10 was in bed and was not able to answer questions. Resident #10 had an indwelling catheter in place. Interview on 6/14/23 at 9:20 AM, the DON stated the MDS nurses were responsible of creating and updating comprehensive care plans. Interview on 6/15/23 at 11:16 AM MDS Nurse C stated Resident #10 was admitted on [DATE] and stated when creating and updating care plans, she referred to physician orders and baseline care plans. MDS Nurse C stated comprehensive care plans were created 21 days (about 3 weeks) after admission and quarterly and/or change in condition. MDS Nurse C stated Resident #10 should have a focus care for urinary catheter. MDS Nurse C stated Resident #10 urinary catheter focus area may have slipped due to the high volume of admission and discharges. MDS Nurse C stated by not including the urinary catheter could affect the monitoring of care Resident #10 received. Did MDS confirm she had not completed a comprehensive care plan? Just say MDS Nurse C failed to develop and implement comprehensive person-centered care 676457 Page 12 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0656 Resident #11 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #11's face sheet dated 06/15/23 revealed admission on [DATE] and readmission on [DATE], and readmission on [DATE] to the facility. Residents Affected - Few Record review of Resident #11's history and physical dated 05/09/23 revealed an [AGE] year-old female diagnosed with Peripheral arterial disease (happens when there is a narrowing of the blood vessels outside of your heart) and diabetes. Record review of Resident #11's MDS dated [DATE] revealed a diagnosis of debility (physical weakness, especially as a result of illness), cardiorespiratory conditions, diabetes mellitus, respiratory failure, and acute respiratory failure with hypoxia. Resident was on oxygen therapy. Record review of Resident #11's order recap dated 06/15/23 revealed order date 05/09/23 oxygen at 1 liter per minute via nasal cannula continuous . Record review of Resident #11's comprehensive care plan dated 06/15/23 revealed that there was no documentation of oxygen in the comprehensive care plan. Observation on 06/13/23 at 10:47 AM revealed Resident #11 had an oxygen tank in her room and a concentrator in the restroom. Neither the tank or the concentrator was in use. Interview on 06/15/23 at 10:23 AM MDS Nurse C stated she was not assigned to Resident #11 and would look into Resident #11's comprehensive care plan. MDS Nurse C stated Resident #11 she had not addressed the oxygen use in the comprehensive care plan dated 06/15/23. MDS Nurse C stated the comprehensive care plan was the residents plan of care for Resident #11 that needed to have oxygen use in the comprehensive care plan. Interview on 06/15/23 at 11:19 AM MDS Nurse B stated she did not see in Resident #11's comprehensive care plan regarding any information regarding oxygen use. MDS Nurse B stated she was responsible for the for Resident #11's comprehensive care plan and did not know why it was not in Resident #11's comprehensive care plan. MDS Nurse B stated Resident #11 not having oxygen use in her care plan was not a risk to her because she had an order. MDS Nurse B stated if there was no order then there would be a risk to the resident because the oxygen was not care planed. MDS Nurse B stated it was required to have the oxygen use in the comprehensive care plan as well. Record review of the facility's policy care plans, comprehensive person-centered policy dated 03/2022 revealed a comprehensive person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs was developed and implemented for each resident. 676457 Page 13 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible for 1 (Resident #206) of 6 residents reviewed for indwelling catheters 1. Resident #206's indwelling catheter tubing was cloudy with solid particles in the tubing and full of urine. 2. Resident #206's catheter tubing was not anchored on resident's leg correctly. This failure place residents at risk of dislodgement of foley and of the collection tube becoming full and allowing urine to flow back into the bladder that could result in a urinary tract infection. Findings include: Record review of Resident #206's face sheet dated 06/14/23 revealed admission on [DATE] to the facility. Record review of Resident #206's history and physical dated 05/27/23 revealed a [AGE] year-old male diagnosed with strokes, paraparesis (partial paralysis of the lower limbs), diabetic (poor control), and general weakness. Record review of Resident #206's admission MDS dated [DATE] revealed ADLs for toilet use as total dependence. Resident had an indwelling catheter, diabetes mellitus, paraplegia, and muscle weakness. Record review of Resident #206's order recap dated 06/14/23 indicated order date 05/26/23 to change foley catheter per facility protocol as needed phone ex: no drainage, sediment buildup, leakage, etc An Order dated 05/26/2023 change foley per facility protocol every shift every 1 month(s) starting on the 25th for 1 day(s). Change urine drainage bag as needed per family protocol. Observation on 06/14/23 at 9:12 AM, Resident #206's catheter tubing from bag to where it entered Resident #206's clothing was full of dark brownish yellow urine. At the bottom of the catheter tube was cloudy sediment. Observation on 06/14/23 at 2:20 PM, Resident #206's catheter tubing on his right leg was not secured into place, allowing the tubing to move freely. Interview on 06/14/23 at 2:38 PM, RN D stated the anchor on the Resident# 206's leg was not strapped. RN D stated it was unhooked and needed to be hooked correctly so it did not move. RN D stated there was a risk to Resident #206 because the Foley could become dislodged pulling on the resident. RN D stated she had changed the foley because it was full of urine and cloudy with sediment. RN D 676457 Page 14 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0690 Level of Harm - Minimal harm or potential for actual harm stated she did not notice the foley was cloudy with sediment and full of urine the day before (06/13/23). RN D stated Resident #206 did have some discomfort. RN D stated when she comes into work, she does her nursing assessments on all the residents but did not notice the foley on Resident #206 if it was full or cloudy or had any concerns. RN D stated if the Foley was not changed it could have caused a urinary tract infection. Residents Affected - Few Interview on 06/15/23 at 3:53 PM, The DON stated urinary catheters are monitored by the nurses on every shift. The DON stated the foley needed to be anchored correctly because the risk to the residents could result in the foley being pulled. The DON stated she was responsible for making sure the nurses were anchoring the foley and making sure the tubing and bag were emptied. Record review of the facility's policy Emptying a urinary collection bag dated 08/2022 revealed the purpose of this procedure was to prevent the collection bag from beginning full and allowing urine to flow back into the bladder. Observe the character of the urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 676457 Page 15 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

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 observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 4 (Resident #4, Resident #11, Resident #23, & Resident #205) of 10 residents observed for oxygen management. Residents Affected - Some 1. Residents #4, #11, #23, & #205 were not having there oxygen tubing dated. 2. Residents #4, #11, #23, & #205 did not have oxygen signs posted outside their bedrooms. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Resident #4 Record review of Resident #4's face sheet dated 06/15/23 revealed admission on [DATE], readmission on [DATE], and readmission on [DATE] to the facility. Record review of Resident #4's history and physical dated 05/22/2023 revealed a [AGE] year-old male diagnosed with chronic respiratory failure. Record review of Resident #4's admission MDS dated [DATE] revealed diagnosis of Chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood). Record review of Resident #4's Order Recap dated 02/23/23 revealed an order for oxygen at 2 liters per minute via nasal cannula continuous during night or PRN during the day. Change oxygen tubing as needed and every Sunday. Ensure to put date when changed. Record review of Resident #4's Care Plan dated 05/21/23 revealed at risk for respiratory distress, hypoxia, shortness of breath, chronic obstructive pulmonary disease which will exhibit signs of wheezing, restlessness, bubbling, and crackling. An intervention was to administer oxygen as ordered. Observation on 06/13/23 at 2:39 PM, Resident #4 had a concentrator in his room but it was not in use. There was no oxygen sign posted outside of the resident's room. Interview on 06/14/23 at 11:48 AM RN H stated Resident #4 had oxygen orders for oxygen use. Observation on 06/14/23 at 12:01 PM, RN H. went into Resident #4's bedroom and stated there was no oxygen sign posted in and outside of the resident's room. Observation on 06/14/23 at 12:19 PM with the DON, the DON went into Resident #4's bedroom and 676457 Page 16 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some verified the resident did not have any oxygen signs posted outside of the resident's room. The DON stated staff needed to post an oxygen sign since oxygen was in use. Resident #11 Record review of Resident #11's face sheet dated 06/15/23 revealed admission on [DATE], readmission on [DATE], and readmission on [DATE] to the facility. Record review of Resident #11's history and physical dated 05/09/23 revealed the resident was an [AGE] year-old female. Record review of Resident #11's MDS dated [DATE] revealed being diagnosed with respiratory failure and acute respiratory failure with hypoxia. Resident was receiving oxygen therapy. Record review of Resident #11's Order Recap dated 05/09/23 ordered for changing of oxygen tubing as needed and ensure to put a date when changed. Change oxygen tubing every Sunday . Date 05/09/23 oxygen at 1 liter per minute via nasal cannula continuous. Record review of Resident #11's Care Plan dated 06/15/23 revealed Resident #11 did not have oxygen therapy or use in her care plan. Observation on 06/13/23 at 10:47 AM, Resident #11 was not using oxygen at the moment. There was an oxygen tank and a concentration in the room. There were no oxygen signs posted above the resident bed or on it . There was no oxygen sign posted outside of the resident's bedroom. Observation and interview on 06/14/23 at 11:54 AM, RN H went into Resident #11's bedroom and stated the was no oxygen sign posted in and out of the resident's room. Observation and interview on 06/14/23 at 11:58 AM,RN H went into Resident #11's bedroom and stated there were no oxygen signs posted on the wall above the resident's bed and or on the bed and outside of the resident's room. Observation and interview on 06/14/23 at 12:17 PM , the DON went into Resident #11's bedroom and stated there were no oxygen signs posted on the wall above the resident's bed and or on the bed outside of the resident's room. Resident #23 Record review of Resident #23's face sheet dated 06/15/23 revealed admission on [DATE] to the facility. Record review of Resident #23's history and physical dated 05/13/23 revealed a [AGE] year-old female was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #23's quarterly MDS dated [DATE] revealed a diagnosis of obstructive sleep apnea. The resident was on oxygen therapy for respiratory treatment. Record review of Resident #23's Order Recap dated 06/06/23 change oxygen tubing as needed and put a date when changed. Change oxygen tubing every Sunday. Date 05/13/23 oxygen at 2 liters per minute 676457 Page 17 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some via nasal cannula continuous every shift for hypoxia. Date 06/06/23 oxygen at 2 liters per minute via nasal cannula continuous. Change tubing as needed. Record review of Resident #23's Care Plan dated 05/19/23 resident was on oxygen therapy. Resident was at risk for respiratory distress, hypoxia, shortness of breath, and had a history of chronic obstructive pulmonary disease. An intervention was to administrator oxygen as ordered. Resident was at risk for ineffective breathing patterns and at risk for nocturnal hypoxia and respiratory distress. Interventions were to apply oxygen as physician ordered and follow oxygen safety precautions. Observation on 06/13/23 at 3:14 PM, Resident #23 was asleep in bed using a nasal cannula with an oxygen concentrator on at 2 liters per minute. Resident #23 did not have any oxygen signs posted above her bed or on the bed and outside of her room. Interview on 06/13/23 at 3:14 PM, a family member stated she had not seen the nursing staff change out Resident #23's oxygen tubing. Observation and interview on 06/14/23 at 11:52 AM , RN H reviewed the orders and stated Resident #23 did have orders for oxygen use on the facility's program. Observation and interview on 06/14/23 at 12:04 PM RN H went into Resident #23's bedroom and stated the resident did not have any oxygen signs posted on the wall above the resident's bed and or on the bed and outside of the resident's room. Observation and interview on 06/14/23 at 12:20 PM the DON went into Resident #23's bedroom and stated the resident did not have any oxygen signs posted on the wall above the resident's bed and or on the bed outside of the resident's room. Resident #205 Record review of Resident #205's face sheet dated 06/15/23 revealed admission on 06/09//23 to the facility. Record review of Resident #205's history and physical dated 05/24/23 revealed a [AGE] year-old male diagnosed with cirrhosis of the liver, clotting disorder, and esophageal varices. Record review of Resident #205's Order Recap dated 06/12/23 indicated oxygen at 2 liters per minute via nasal cannula continuous. Change tubing weekly and as needed. Record review of Resident #205's Care Plan dated 06/15/23 did not indicate any information regarding oxygen therapy/use. Observation on 06/13/23 at 9:54 AM Resident #205 was see in bed with a nasal cannula on with a concentration in use at 2 liters per minute. There were no oxygen signs posted above the bed and or on the bed itself. There was no oxygen sign posted outside of the resident's room. Observation and interview on 06/14/23 at 11:50 AM , RN H reviewed the orders and confirmed Resident #205 did have orders for oxygen use on the facility's program. Observation and interview on 06/14/23 at 11:56 AM RN H. went into Resident #205's bedroom and 676457 Page 18 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0695 stated the was no oxygen sign posted in and out of the resident's room. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 06/14/23 at 12:15 PM the DON, went into Resident #205's bedroom and stated that resident did not have any oxygen signs posted on the wall above the resident's bed and or on the bed outside of the resident's room. Residents Affected - Some Interview on 06/14/23 at 12:10 PM, RN H stated oxygen signs mean that we need to be cautious because a resident could be on oxygen. RN H stated this was meant for the families, staff, and visitors. RN H stated the residents who are on oxygen have to have an oxygen sign posted outside of their rooms. RN H stated a risk still existed for Resident #4, #11, #23, & #203 because there were no oxygen signs posted outside of their rooms. RN H stated she needed to follow up with ensuring that oxygen signs are posted up for those residents on oxygen. RN H stated the risk to the residents could be an explosion. RN H stated she was unaware that the facility policy stated resident with oxygen also need to have oxygen signs post above their beds on them. RN H stated nasal cannulas needed to be changed out every week on Sunday by the night shift nurses. RN H stated the oxygen tubing needed to be labeled/dated. RN H stated the risk could be a respiratory infection if they are not changed out. Interview on 06/14/23 at 12:27 PM, the DON stated oxygen signs let everyone know that there was oxygen in use in the room. The DON stated it let people know for the safety of the residents not to smoke because of the oxygen in use. The DON stated any oxygen tanks or concentrator would warrant an oxygen sign to be posted outside of the resident's room. The DON stated she believed that there would be no risk because it was a smoke free facility. The DON stated she oversaw that oxygen signs are being posted. Interview on06/15/23 at 9:49 AM LVN E stated oxygen signs are posted outside of the resident's bedroom letting everyone know that there was oxygen in use in the room. LVN E stated oxygen signs are required if the resident had a concentrator, portable, or a tank in the room. LVN E stated oxygen signs indicate a precaution, so people do not light up lighters. LVN E stated the admitting nurse, or the floor nurses ensure oxygen signs are posted. LVN E stated staff might not realize a resident was on continuous oxygen and could run out or something happen, and the resident's oxygen stats drop. LVN E stated oxygen tubing needed to be changed out once a week on Sunday by the night shift nurse. LVN E stated the oxygen tubing was changed out because you want to make sure the line was clear, ensure proper function of the line, and the line was clear. LVN E stated the risk of not changing the oxygen tubing could be bacterial growth and a possible respiratory infection for the resident. Interview on 06/15/2023 at 4:55 PM the DON stated they did not have a facility policy on oxygen labeling/dating for tubing. Record review of the facility's oxygen administrator policy dated 10/2010 revealed place an Oxygen in use sign on the outside of the room entrance door. Close the door. Place an Oxygen in use sign in a designated place on or over the resident's bed. 676457 Page 19 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate system is in place for acquiring, dispensing and storage of medications for pharmaceutical services; failed to have an established system in place for accurate reconciliation for 3 (Hall 100, Hall 300 and Hall 500) of 5 halls that had residents with orders for controlled substances and monitoring of over-the-counter medication in one medication storage room. The facility failed to ensure Licensed Staff were signing Controlled Drugs Count Record when Controlled Drugs were reconciled at change of shift according to facility policy. The facility failed to monitor expiration dates on the over-the-counter medication in the medication storage room leaving expired medication on the shelves. This deficient practice could affect residents by placing them at risk of drug diversion and receiving medication that will not provide the same result. Findings included: Record review and interview on [DATE] at 09:22 AM with RN H, the narcotic count sheet for the month of [DATE] on 100 hall was missing the signatures for 2-10pm shift on [DATE]. RN A stated, she had worked a double on [DATE] and forgotten to sign the narcotic sheet. RN H stated she had counted with the night nurse prior to handing over the keys to the medication cart that included the narcotics. RN H verbalized she was trained to sign narcotic count sheets after she counts narcotics and the count was correct at the beginning or end of her shift, because she was assuming responsibility of the narcotics inside the cart. Record review and interview on [DATE] at 09:56 AM with RN M, the narcotic count sheet audit for the month of [DATE] on 300 hall was missing the signatures for sign out at 2pm on the 6 am to 2 pm shift on [DATE]. RN M stated, she had not noticed the blank on the narcotic count sheet. RN M left space blank and stated we are trained to sign at the moment when we are done, she would leave it blank. Record review and interview on [DATE] at 10:05 AM with LVN E, the narcotic count sheet audit done for the month of [DATE] on 500 hall was missing the signatures for sign out at 2pm on the 6 am to 2 pm shift on [DATE]. LVN E stated, she had not noticed the blank on the narcotic sheet and proceeded to sign it right away. She stated I know I counted, must have just closed the binder that contained the narcotic count sheets while I was giving report to the other nurse. LVN E, stated she was trained that narcotic count sheets are signed at the beginning and end of every shift to make sure the count of narcotics inside the medication cart was correct. She stated they are responsible for the narcotics inside and if we noticed a blank in the narcotic sheet count, she would have notified my DON. Record review of the [DATE] narcotic count sheets verification forms revealed the following: -1 signature missing for January, -1 signature for February 2023, and 676457 Page 20 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0755 -1 signature for [DATE]. Level of Harm - Minimal harm or potential for actual harm Interview with the DON on [DATE] at 12:05 PM revealed staff need to have been signing the narcotic count sheet after they have counted narcotics at the change of every shift or any time, they hand over the keys to another staff member. The DON stated, since the nurses are signing after a narcotic count stating there were no discrepancies both nurses need to ensure that there are signatures are present prior to exchanging the keys to medication cart. Narcotic count sheets are important, stated the DON, because they ensure there are no discrepancies and diversion of narcotics. Residents Affected - Some Observation on [DATE] at 11:13 with the DON in the medication storage room revealed 5 bottles of Thiamin Vitamin B-1 with 100 tables with the expiration date of 05/23 stored in cabinet. Interview on [DATE] at 02:13 PM with CNA I revealed she was assigned to central supply, and she stocked over the counter medication weekly and does monthly audits in the medication storage room for expiration dates on over-the-counter medication. CNA I stated when doing audits, I remove medication that will expire within 3 months, to prevent expired medication from being used by staff. CNA I stated I do this because it was very important for residents to get their prescribed medication and when giving expired medication the resident might not get the full effect of the medication or it can cause harm to the resident. On [DATE] at 12:09 PM the DON stated she goes into the medication storage room and performs random audits to ensure there is not expired over the counter medication. The DON stated, the nurses should not have expired over-the-counter medication in their medication cart they are trained to double check expiration dates prior to administering medication, and when opening a new bottle of over-the-counter medication. The DON stated expired medication should not be given to residents because they might not get the full potency of the medication. On [DATE] at 05:00 PM prior to exit attempted for the third time to obtain the Policy and Procedure for Narcotic count from the DON, policy not provided. Record review of the facility ' s Storage of medication policy dated 11/2020 revealed in part discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility ' s Administering medication policy dated 04/2019 revealed in part the expiration /beyond use dated on the medication label is checked prior to administration, when opening a multi-dose container, the date opened is recorded on the container. 676457 Page 21 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #30) of 6 resident ' s reviewed for psychotropic medication, . The facility failed to ensure that Resident #30 did not receive antipsychotics (quetiapine fumarate and aripiprazole) that were not necessary to treat a specific condition These failures could put residents at risk of side effects from unnecessary psychotropic medications. Findings included: Record review of Resident #30 ' s face sheet dated 06/15/2023 documented he was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #30 ' s facility History and Physical dated 12/28/2022 documented he had diagnoses of vascular dementia with behavioral disturbance, and poor mental status. Record review of Resident #30 ' s quarterly MDS dated [DATE] documented he had a BIMS of 7 (severe cognitive impairment). He had no symptomatic behaviors over the 7-day lookback period. He had diagnoses including non-Alzheimer's dementia, anxiety disorder and depression. He had received antipsychotic, antianxiety and antidepressant medications 7 out of the 7 days in the look-back period. It was documented that no gradual dose reduction had been attempted. Record review of Resident #30 ' s care plan dated 01/31/2023 documented he was at risk for adverse consequences due to receiving psychotropic medications aripiprazole (generic for Abilify, an antipsychotic used to treat schizophrenia) and quetiapine (generic for Seroquel, an antipsychotic used to treat schizophrenia) for agitation. Record review of Resident #30 ' s physician ' s order dated 01/29/2023 documented that the resident was to receive 12.3 mg of quetiapine (an antipsychotic) at bedtime for agitation. Record review of Resident #30 ' s physician ' s order dated 12/28/2022 documented he was to receive 2 mg of aripiprazole at bedtime for bedtime major depressive disorder. Record review of Resident #30 ' s June 2023 MAR (accessed electronically 06/15/2023) documented he had received 2 mg of aripiprazole for depression every day at bedtime and 12.5 mg of quetiapine for agitation every day at bedtime. Record review of Resident #30 ' s pharmacy note dated 05/26/23 documented the resident was on two low-dose anti-psychotics (Ability 2 mg and Seroquel 12.5) and that one should be discontinued and the other increased. The physician responded that the psychiatrist should be consulted. The physician stated he had been gradually tapering Seroquel and talked with a family member who was comfortable 676457 Page 22 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0758 with the plan. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #30 ' s Medication Recap for 06/01/2022 to 06/30 2023 documented that the resident had been receiving 12.5 mg quetiapine/Seroquel from 10/08/2022 to 12/10/2022, and between 12/28/2022 and 1/15/2023. His dosage of quetiapine/Seroquel increased to 25 mg from 01/15/2023 and 01/29/2023, then it was decreased to 12.5 mg on 06/15/2023. Residents Affected - Some In an interview on 06/15/23 at 03:08 PM the DON said regarding Resident #30, agitation was not an appropriate diagnosis for administration of quetiapine. She stated a note from the psychiatrist (date not provided) said to continue Seroquel for sleep, restlessness and agitation. The DON said that use of an antipsychotic could cover up what was truly happening with a resident. She said quetiapine had a black box warning regarding side effects and risks of being on those meds. Record review of the facility ' s policy, Psychotropic Medication Use, dated July 2022 documented that residents would not receive medications that were not clinically indicated to treat a specific condition. Psychotropic medications would not be given on a PRN basis beyond 14 days unless the prescriber documented the rationale for extending the use and included the duration for the PRN order. Record review of drugs.com on 06/20/2023 documented that quetiapine may cause serious side effects, including risk of death in the elderly with dementia. It said Medicines like this one can increase the risk of death in elderly people who have memory loss (dementia). This medication is not for treating psychosis in the elderly with dementia. The website documented that aripiprazole was an antipsychotic used to treat schizophrenia. It said Aripiprazole is not approved for use in older adults with dementia-related psychosis . Aripiprazole may increase the risk of death in older adults with dementia-related psychosis and is not approved for this use. 676457 Page 23 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, 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 kitchen sanitization: residents . 1. Foods in dry store, walk in, and freezer not dated or labeled properly. 2. Food containers and food bags not properly sealed in the kitchen and walk-in. 3. Stove food catchers/food traps not being cleaned regularly. 4. Staff not wearing hair nets when entering the kitchen. 5. Food Temperature Logs were not filled out correctly for May 2023 and June 2023. 6. Clean Documentation Form not filled for the week of June 07, 2023, to June 14, 2023. 7. Low Temperature dish machine log not being filled out to ensure the water temperature was hot enough to kill bacteria and the water was sanitizing according to the Parts per million to kill bacteria. 8. Daily Scheduled logs not being followed to ensure sanitation of kitchen equipment and labeling/ rotation of foods. 9 Kitchen trash can without a lid. 10. CNA failed to wash hands before distributing drinks to residents. These failures could affect residents by placing them at risk of food borne illness. 676457 Page 24 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0812 Findings include: Level of Harm - Minimal harm or potential for actual harm Observation of the kitchen on 06/13/23 from 8:10 AM to 10:13AM revealed the following: *8:10AM the kitchen trashcan had no lid. Residents Affected - Some *8:15 AM, the female cook's hair was exposed while she was in the prep line prepping food. * 8:28 AM, in the dry storage there were dry beans, rice, flour containers in dry storage did not have an expiration date. *8:35 AM, the Administrator in Training walked into the kitchen with a hairnet on that was exposing hair as the hairnet was not on correctly. * 8:37 AM , in the dry storage area there were 3 bags of pasta did not have an expiration date and a bag of cereal was not labeled. *8:45 AM, in the freezer a box of garlic bread and a box of shredded chicken taquitos were open and did not have the label. * 8:54 AM, in the refrigerator there was a semi wrapped up cucumber in saran wrap that had something growing on it and not closed with a good seal. Two metal sheets had prepping of lettuce, tomato, onions, and pickles that did not have a label. A bag of cilantro that had no label. A bag of cilantro wrapped up that was slimy, dark, and wet. * 9:00 AM, a bread shelf (near the director of dietary's office) contained bread that was not labeled. Next to the bread shelves on the steel prep table there were dietary staff personal items (a black trash bag, a water bottle, container of protein, a radio with the dirty cord on the table) near the silverware and bread. *9:06 AM, a box of corn starch was open exposing the powder, Containers filled with Cajun, ground mustard seed, and ground white pepper seasonings had lids that were open. *9:14 AM, in the cooking line the grill sheet catcher was full of foods particles and food pieces; drainage of fluids was on the foil. 9:16 AM, the dish temperature log for the month of June was not filled out for the 9th, 11th, 12th, and the 13th. The Food temperature log on the serving line was not filled out correctly for the months of May (dinner 05/11, 05/12 blank) & June (dinner 06/11 was blank). *10:13 AM, the dietary staff was seen with her braided hair hanging exposed and not within the restraint of the hairnet and the cleaning documentation form was not filled out for 06/07, 06/08, 06/09, 06/10, 06/11, 06/12, 06/13, 06/14. Interview on 06/13/23 from 8:11 AM to 10:14AM,- [NAME] J stated they normally do not have their trash cans with lids inside the kitchen and had always had it that way. [NAME] J stated foods needed to have an expiration date on them to know when foods would be good to consume by the residents. [NAME] J stated labels on foods need to have an expiration date. [NAME] J stated the importance of labeling foods was to know the difference from older foods from the new foods. [NAME] J stated without the 676457 Page 25 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some foods being labeled there could be a negative outcome. [NAME] J stated any time someone was in the kitchen they need to have on a hairnet and beard guard. [NAME] J stated the cereal did not have a visible label. [NAME] J stated dietary staff have been trained on labeling and dating foods. [NAME] J stated when opening foods dietary staff are to use a label, use by date, date received, and date opened. [NAME] J stated the cucumber was not wrapped properly and the cucumber was moldy. - [NAME] J stated person stuff are not to be near any food, silverware, or area where foods can come into contact with it. [NAME] J stated if the personal items did come into contact it could be cross contamination. [NAME] J stated the containers were to be closed securely to prevent bugs, dirt, and other foreign objects from going into the containers. [NAME] J stated if those items were used in the food and served to the residents, the resident could get sick from their stomachs. [NAME] J stated it was cleaned once a week. [NAME] J stated if the grill sheet catcher had grease or was dirty with food it could light up on fire. [NAME] J stated not cleaning out the grill catcher could attract mice or pests. [NAME] J stated the dietary staff are to be taking the temperature and sanitization to ensure the temperature was hot enough to kill the bacteria and to ensure the water was sanitizing the dishes. [NAME] J stated dietary staff are to fill out the food temperature log to ensure the foods are at the correct temperature to prevent bacteria growth. [NAME] J stated the risk of not taking the temperature could get a resident sick with food poisoning. [NAME] J stated hairnets are to restraint hair and any exposed hair can fall into the foods contaminating it. [NAME] J stated dietary staff are to fill out the cleaning form ensuring kitchen equipment was being cleaned. Observation on 06/13/23 at 10:30 AM with the Director of Dietary and Dietitian, It was observed that 3 female dietary staff had exposed hair that was not restrained by the hairnet. Interview on 06/13/23 at 10:35 AM, with the Director of Dietary and Dietitian. The Director of Dietary stated the hairnet was to restraint hair so that it did not fall into the food. Dietitian stated hairnets are to cover the hair so to keep it out of the food. The Director of Dietary stated it was not appropriate that the hair was exposed. The Director of Dietary stated the dietary staff have been trained regarding the ware of the hairnet. Interview on 06/13/23 at 9:18 AM Director of Dietary stated the dietary staff are to filling out the low temperature log to ensure the water was hot enough to kill bacteria and germs and the chemicals are sanitizing the dishes. Director of dietary stated she oversaw that the dietary staff are filling out the low temperature logs. Observation on 6/13/23 at 11:57 AM CNA I was called out of dining area by another staff member and returned at 11:58 AM with cell phone in hand. CNA I walked straight to drink cart and started pouring drinks into cups. CNA I did not wash hands and did not use hand sanitizer before pouring drinks. Interview on 6/13/23 at 12:01 PM CNA I stated she had been working for almost 4 years. CNA I stated she had received infection control training upon hire and annually. CNA I stated she had received training on washing hands after interacting with each resident and before assisting with serving drinks and meals. CNA I stated by not washing hands, residents were exposed to acquiring an infection due to infection cross contamination. CNA I stated she forgot to wash her hands before assisting with serving drinks. Interview on 06/14/23 at 10:27 AM [NAME] L stated it was important to have a hairnet on so that hair does not fall into the food. [NAME] L stated the hair belongs within the hairnet and men need beard guards. [NAME] L stated if food got in the food, and it was served it would be disgusting. [NAME] L stated the importance of labeling foods was to make sure it was not spoiled. [NAME] L stated 676457 Page 26 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some labeling foods needed to have the date, name, and how many days it could last in the refrigerator, and expiration date. [NAME] L stated incorrect labeling could get residents sick if served to them. [NAME] L stated the grill sheet catcher looked pretty bad with food and spilled on grease. [NAME] L stated it needed to be changed out because it was gross and a hazard. [NAME] L stated the food particles and grease could become flammable. [NAME] L stated dietary staff have lockers to put away personal belongings which should not be left out in the food prep areas. [NAME] L stated personal items are dirty and could fall into the foods. [NAME] L stated if served could be an infection control issue [NAME] L stated foods are to be closed and sealed, so no air goes inside the container, to keep the food item fresh, and so bugs won't go inside. Interview on 06/14/23 at 10:50 AM [NAME] J stated food temperature logs are to be filled out to make sure the food was at the proper temperature being served to the resident at a safe temperature. [NAME] J stated dietary staff not filling out the temperature log could result in something happening to the residents like vomiting, diarrhea, upset stomach, and nourishing. [NAME] J stated the purpose of the dish temperature log was to ensure the chemicals are getting rid of the contaminates and excess food, and to make sure the temperature are to temp and sanitizing. [NAME] J stated personal items are to be kept in lockers and should not be around the food prep area. [NAME] J stated personal items may end up in the food. Interview on 06/14/23 at 11:21 AM Director of Dietary stated all dietary staff have been trained on taking temperatures before servicing food, labeling, cleanliness of the kitchen. Director of Dietary stated foods labeled must have the food name, expiration, date received, and open date. Director of Dietary stated if foods are labeled incorrectly and served to the residents, they could get a foodborne illness or stomachache. Director of Dietary stated containers and wrapped foods need to be seal tight to keep air out and keep bacteria from growing. Director of Dietary stated personal items should be kept in lockers or in her office. Director of Dietary stated personal items in the food prep area can cross contaminate the foods. Record review of the facility's preventing foodborne illness- employee hygiene and sanitary policy dated 10/2017 revealed hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and lines. Personnel may not keep personal items in food preparation area. Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task and or after engaging in other activities that contaminate the hands. Record review of facility's dietary services - food and nutrition services policy dated 11/2022 revealed food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that the hair does not contact food. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. Record review of facility's Inservice [NAME] policy dated 2010 revealed the cook on each shift was responsible for keeping the range as clean as possible during the preparation of the meal. Wash drip pans as needed and or according to the cleaning schedule. Record review of facility's food preparation and service policy dated 11/2022 revealed food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Danger zone means temperatures above 41 degrees and below 135 degrees that 676457 Page 27 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0812 allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Level of Harm - Minimal harm or potential for actual harm Record review of facility's food receiving, and storage policy dated 11/2022 revealed refrigerated/frozen storage - all foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). Residents Affected - Some 676457 Page 28 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 3 (Dumpsters #1, #2, & #3) of 3 dumpsters containers and 1 (utility tilted trash cart) of 1 utility tiled trash cart reviewed for food safety requirements. Residents Affected - Some 1. Three dumpsters (#1, #2, & #3) had their dumpster lids open. 2. One utility tiled trash cart did not have a lid. 3. Three dumpsters in the back of the facility had trash on the floor outside and around the dumpsters. 4. One utility tiled trash cart in the back of the kitchen had cigarette buds on the floor outside near grease. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided an unsafe, unsanitary and uncomfortable environment. Findings include: Observation on 06/13/23 at 8:11 AM with [NAME] J, immediately outside of the back kitchen door was a utility tilted trash cart that had no lid. The trash container had a brown bag, mini plastic cups containers, and various other pieces of trash. Near the cart was a pile of cigarette buds on ground next to some grease that had dripped on the floor. At 8:14 AM three dumpsters behind the facility all had their lids open. From around 20 feet away from the middle dumpster (#2) three white garbage bags were visible. There was a plastic straw on the ground and near it was a piece of trash, and a nasal inhaler box on the ground. Interview on 06/13/23 at 8:16 AM with [NAME] J, [NAME] J stated the dumpster lids were not to be left open as they could attract pests. [NAME] J stated he does not know who was responsible for the trash and dumpsters. At 8:19 AM [NAME] J stated the dietary put kitchen trash bags in the utility tiled trash cart and fill it. [NAME] J stated once it was full, they take it over to the dumpsters to throw it. [NAME] J stated he did not know if the utility cart ever had a lid. [NAME] J stated the utility cart could attract pests since the trash was exposed. [NAME] J stated the facility was a smoke free facility, but next door was the assisted living facility, and they do smoke. [NAME] J stated the grease on the floor and the cigarette buds near could be hazardous possibly causing an oil flame. Interview on 06/14/23 at 10:27 AM, [NAME] L stated she would think the dumpster lids were to remain closed after throwing out the trash. [NAME] L stated it could attract pests and could be stinky. [NAME] L stated she had not been told about the trash on the floor near or around the dumpsters. 676457 Page 29 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/14/23 at 10:50 AM, the Director of Dietary stated the dumpster lids are to remain closed. The Director of Dietary stated having the lids open could attract pests. The Director of Dietary stated she did not know who was responsible for the dumpster area. The Director of Dietary stated she was not sure if the utility tiled cart needed to have a lid. Record review of facility storage areas, maintenance policy dated 12/2009 revealed trash receptacles and surrounding area must be kept in clean and orderly manner. 676457 Page 30 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure medical records on each resident were complete and accurately documented for 1 of 6 (Resident #259) residents reviewed for accuracy of clinical records. The facility failed to accurately document Resident #10 had over the counter medication in his possession via electronic and/or paper charting. This failure could have placed residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings include: Record review of Resident # 259 ' s face sheet dated 6/14/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident # 259 ' s local hospital history and physical dated 5/22/23 revealed diagnoses of major depressive disorder. Record review of Resident # 259 ' s MDS admission assessment dated [DATE] was not yet completed, but revealed a BIMS score of 15, he was cognitive aware. Record review of Resident # 259 ' s complaint/ grievance report dated 6/9/23 revealed complaint was communicated to Administrator and concerns detail was being verbally abused by staff. Describe concern in detail revealed nurse called him a drug dealer or drug addict. Findings of investigation revealed nurse denied calling Resident #259 a drug dealer or drug addict. Results of actions taken section revealed talked with Resident #259 related regarding nurse denied calling him a drug dealer and/or drug addict. Reportable to state agency section revealed no was marked off. Record review of Facility ' s written reports dated 6/9/23 revealed Resident #259 was stable no documentation of over-the-counter Tylenol 8-hour Arthritis Pain bottle of 650MG medication found in his possession. Record review of Resident #259 ' s electronic progress notes dated June 2023 revealed no documentation found related to Resident #259 ' s over the counter medication Observation and interview on 6/13/23 at 10:23 AM Resident #259 was alert and oriented to person, place, time and event. Resident # 259 stated he had a confrontation with LVN A last Friday. Resident # 259 stated he had requested pain medication from LVN A and it was denied by him. Resident # 259 stated LVN A called him a drug addict. Resident # 259 stated he reported this incident to the Administrator. Resident #259 asked Surveyor to open the bottom drawer from his bedside nightstand and open the side pocket of a red duffle bag. A bottle of Tylenol 8-hour Arthritis Pain bottle of 650 MG each tablet was found in the duffle bag. Resident #259 stated that LVN A was notified by him, and he attempted to get the medication from him but did not let him. Resident #259 stated he would not take the medication unless it was prescribed from the MD and would give up the medications when/if asked for them. Resident #259 stated no other staff has questioned or attempted to get the Tylenol medication 676457 Page 31 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0842 bottle from him. Level of Harm - Minimal harm or potential for actual harm Interview on 6/13/23 at 10:38 AM, LVN K stated he was not aware Resident #259 had over the counter medication in possession. LVN K stated he had not received reports regarding over-the-counter medication, and it was not documented on Resident #259 electronic records. LVN K stated when an incident occurs, he was trained to report and document in resident electronic record for nurses to be aware and for proper ongoing monitoring. Residents Affected - Few Interview on 6/13/23 at 10:51 AM, the DON stated she received report from LVN A last Friday 6/9/23 regarding Resident #259 having over the counter medication in possession. The DON stated LVN A should have documented Resident #259 electronic record; she checked electronic records and stated there was no documentation regarding the incident. The DON stated LVN A could have documented in electronic or written reports; the DON checked written reports and stated there was no documentation regarding incidents. The DON stated nurses received training on accuracy of documentation upon hire and as needed. The DON stated she was responsible for ensuring documentation was accurate and would conduct spot checks at least once a week. The DON stated by LVN A not documenting Resident #259 had over the counter medication could affect the ongoing monitoring he received related to possible medication interactions. Interview on 6/14/23 at 11:47 AM LVN A stated last Friday Resident #259 had showed him a bottle of Tylenol he had at bedside and educated him on danger of having and taking medication that was not prescribed by the MD. LVN A stated he notified the DON and MD. LVN A stated he had texted the MD, he referred to his phone and stated he never sent the report related to over the counter medication to the MD. LVN A stated when an unusual event occurred nursing staff was trained on documenting on electronic record or 24/7 written report. LVN A stated he did not document because he forgot. LVN A stated by not documenting the incident and actions taken could affect ongoing monitoring provided to Resident #259. The medication was left with Resident #259. Record review of the facility ' s Charting and Documentation policy dated July 2017 revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medial record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response. 1- Documentation in the medical record may be electronic, manual or a combination. 2- The following information is to be documented in the resident medical record: events, incidents or accidents involving the resident. 3- Documentation in the [NAME] record will be objective, complete, and accurate. 676457 Page 32 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

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 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 1 (Resident #44) of 11 residents and treatment cart reviewed for infection prevention and control. Residents Affected - Some 1.The facility failed to ensure that Resident #44 ' s nebulizer treatment mask was covered when not in use. 2.The facility failed to ensure supplies in the treatment cart were sealed properly. These failures could increase residents ' risk of respiratory infections. Findings included: 1.Record review of Resident #44 ' s face sheet documented he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #44 ' s History and Physical dated 04/21/2023 documented he had diagnoses including tongue cancer and dysphagia (problems swallowing) related to tongue cancer, Parkinson ' s disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and a history of aspiration pneumonia (lung infection lungs caused by breathing in food or liquid). He had a feeding tube. Record review of Resident #44 ' s 5-day MDS dated [DATE] documented his BIMS was 10 (moderate cognitive impairment). His diagnoses included aphasia (difficulty speaking) and dysphagia. Record review of Resident #44 ' s care plan dated 06/11/2023 documented he had altered respiratory status and difficult breathing related to aspiration pneumonia. Interventions included he would be administered medications and nebulizer treatments (treatment where medicine is inhaled) as ordered. Record review of Resident #44 ' s physician ' s progress note dated 06/11/2023 documented that the resident had worsening shortness of breath. The physician diagnosed him as having aspiration pneumonia and to have a DuoNeb (a breathing treatment) treatment every four hours. Record review of Resident #44 ' s physician ' s order dated 06/11/2023 documented he was to have inhaled treatments of Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML four times a day for shortness of breath. In observation on 06/13/23 at 09:15 AM an uncovered nebulizer treatment mask was seen lying on top a nebulizer machine on Resident #44 ' s bedside table. In an interview on 06/13/23 at 09:21 AM, RN M said Resident #44 ' s nebulizer mask should be covered. She said if the nebulizer treatment mask was not covered it could pose a risk of infection to the resident if he breathed in contaminants from the mask. She said he was receiving breathing treatment because he had an episode of emesis (vomiting) with aspiration over the weekend. RM M did not know who had last used the nebulizer to provide breathing treatments to Resident #44. 676457 Page 33 of 34 676457 06/15/2023 The Bartlett Skilled Nursing and Assisted Living 221 Bartlett Drive El Paso, TX 79912

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #44 ' s MAR for June 2023 (accessed 06/15/2023) documented he had received inhalation treatments of Ipratropium-Albuterol Inhalation Solution four times a day beginning the evening of 06/11/2023 through the night of 06/13/2023. 2.Observation and interview on 06/13/23 at 11:05 AM with the ADON revealed treatment cart had 14 dressings supplies that had been previously used and cut with scissors and placed back in the cart to be utilized for other residents. Opened to air and exposed 4x4 gauzed package in treatment cart. The ADON stated several staff members utilized treatment cart and place supplies back in the cart instead of throwing them away. The ADON stated, he would be disposing of the open dressings, and they should not be in treatment cart since they are open. The ADON stated reusing these dressings lead to cross contamination. Interview with the DON on 06/13/23 at 11:35 AM revealed the treatment cart should be maintained clean without any open dressing or gauze. If the gauze or dressing was left open to air and exposed or taken from room to room, it can lead to cross contamination and infection. Record review of facility ' s Dressings, Dry/Clean Policy dated 09/2013 revealed in part open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface, place in a clean field and using clean technique open other products example prescribed dressing. 676457 Page 34 of 34