Health inspection·April 20, 2023

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 interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that re to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident # 71) of twenty residents reviewed for care plans. The facility failed to develop a comprehensive care plan to address Resident # 71's oxygen via nasal canula and bipap machine use which was being administered by the facility. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident # 71's face sheet, dated 4/20/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), chronic and acute respiratory failure. Review of Resident # 71's MDS, dated [DATE], revealed the resident was receiving respiratory treatments and had shortness of breath or trouble breathing when lying flat. The MDS indicated Resident # 71 had a BIMS score of 14 meaning she had little to no cognitive impairment. Review of Resident # 71's Progress note, dated 4/17/23 written by the Nurse Practitioner (NP) revealed obstructive sleep apnea (OSA) and chronic respiratory failure were listed under Active Medical Problems. Review of Resident # 71's admission note written by LVN D on 4/03/23 at 9:39 PM indicated the resident was on Oxygen at 2-3 L continuous and daughter accompanied, brought personal bipap. Review of Resident # 71's nursing progress note, dated 4/04/23 at 4:05 AM written by LVN E indicated .pt tried new cpap and struggled with feeling claustrophobic with on, she wore for approx 3 hours then pt removed and wanted o2 back on and will attempt again every night til she feels comfortable to wear throughout the night . Review of Resident # 71's physician orders on 4/18/23, 4/19/23 and 4/20/23 revealed there was no order for oxygen via nasal canula nor was there any order for Bipap machine. Page 1 of 17 676472 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident # 71's care plan revealed there was no care plan addressing her diagnosis of COPD, oxygen use, or bipap use. Observation and interview on 4/18/23 at 11:50 AM revealed Resident # 71 on Oxygen via nasal canula in her room. The oxygen humidifier was dated 4/10. A Bipap machine was noted at Resident's bedside which Resident # 71 indicated she used it at night. Observation and interview on 4/20/23 at 10:31 AM revealed Resident # 71 seated in her wheelchair on O2 via nasal canula with the oxygen humidifier dated 4/10. The humidifier barely had any water left in it. Bipap machine was noted on bed stand. Resident # 71 stated the nurse checked her oxygen machine once in a while to make sure the setting was right and at night the nurse helped her get the head piece on for the bipap. Interview on 4/20/23 at 10:37 AM with RN F, revealed Resident # 71 was on Oxygen continuously and wore a bipap at night. She stated the night shift changed the tubing and humidification weekly. She stated the night shift helped Resident # 71 put on the bipap machine. Interview on 4/20/23 at 1:54 PM with LVN D, revealed she worked evenings with Resident # 71, and she helped her put on the bipap at night. Interview on 4/20/23 at 4:09 PM with DON revealed the MDS nurses were responsible for updating care plans. The DON stated care plans were important and should be accurate because that is what staff can reference to see what residents needed. Interview on 4/20/23 at 4:20 PM with LVN H revealed she was one of the 3 MDS nurses responsible for updating careplans. LVN H stated Care plans needed to be accurate and were important because they were the plan of care for the residents and all staff referred to the care plan to see what residents needed. LVN H stated she did not complete the MDS for Resident # 71, but her colleague who was already gone for the day had completed it. LVN H stated there were no orders for the oxygen or bipap and that is why it did not trigger the CAA on the MDS. LVN H stated she could not say why her colleague documented the oxygen therapy on the MDS but did not document it in the care plan. LVN H stated had she completed the MDS for Resident # 71 she would have updated the care plan and informed the DON that there were no orders so that the DON could follow up. LVN H stated the oxygen and bipap were included in the baseline care plan but did not get pulled into the comprehensive care plan. LVN H stated normally everything was consistent: the orders, the MDS and the care plan. Review of the facility's Patient Care Management System Assessments policy, dated November 2017, reflected the following: A comprehensive, Person-centered Plan of Care, consistent with the resident rights Care Plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon each change in condition and upon re-admission. The care plan must be based on assessments completed within the previous 15 months in the Patient's/Resident/s active record and use the results of the assessments to develop, review and revise the Patient's/Resident's comprehensive care plan. Review of the facility's Protocol for oxygen administration policy, updated March 2019, reflected the following: Patients with Oxygen therapy will have their Plan of Care updated to reflect their Oxygen use. 676472 Page 2 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one resident (Residents #69) of three residents reviewed for ADL care. Residents Affected - Few The facility failed to ensure Residents #69 was provided showers as scheduled. These failures could place residents at risk of not receiving personal care services and of having a decreased quality of life. The findings include: Review of Resident #69's face sheet , dated 04/20/23, revealed a [AGE] year-old woman, admitted to the facility on [DATE] with diagnoses of acquired absence of left and right leg above the knee, Type 2 Diabetes Mellitus, chronic kidney disease, glaucoma (a group of eye conditions that can cause blindness), age related nuclear cataract (opacification and coloration in the center of the lens and a major cause of blindness), major depressive disorder, recurrent, and anxiety disorder. Review of Resident #69's significant change MDS assessment, dated 01/06/23, reflected a BIMS of 15 which indicated she was cognitively intact. Further review of the MDS reflected Resident #69 had no psychosis or behaviors (including refusal of care) during the past seven days. Resident #69 required supervision of one person for transfers, dressing, toilet use, and personal hygiene. She also required the physical assist of one person for transfer only, during bathing. Review of Resident #69's care plan, dated 04/20/23, reflected she had a self-care deficit and requires assistance with ADL's. The goals included will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days. Interventions included Assist with ADLs as needed. Assist with shower, oral, hair and nail care as needed, as scheduled and prn. Set up assist with dress according to climate and monitor appearance d/t impaired vision. Observation and interview on 04/18/23 at 10:32 AM Resident #69 was up in her wheelchair, dressed and appeared well-groomed, she had bilateral above the knee amputations. Resident #69 stated she received Good care when they want. When asked about showers she said she maybe would get one shower a week if the right CNA was there. Resident #69 said she was supposed to received Monday, Wednesday, and Saturday showers. She stated, they (Facility staff) never came to get her for a shower, she had to tell them she wanted a shower. They did not ask her if she wanted one. Sometimes the staff would go and tell the ADON, she had refused a shower, but the only time she would refuse was if she did not feel good. She said she would like more than one shower a week and a lot of times when she would ask, they would say they were short staffed and she would not get one. Resident #69 also said she had informed the ADON about all of this and no change was noticed. Review of Resident #69's clinical note dated 03/24/23 revealed she refused a shower that day due to her arm hurting. This was the only noted refusal of any shower noted in the clinical notes for March 19, 2023, through April 19, 2023. On 04/19/23 at 1:24 PM surveyor requested Resident #69's shower sheets or documentation of her showers/baths in an e-mail to the Administrator along with two other residents. At 3:54 PM the DON 676472 Page 3 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0677 brought the other two but not Resident #69's. Level of Harm - Minimal harm or potential for actual harm An interview with the DON on 04/19/23 at 4:18 PM revealed that a number 8 on the ADL verification sheets meant it did not occur, and the 0 meant the resident did it themselves. The DON also said the sheet she had provided included both showers and bed baths because it just showed that bathing occurred, and she was not able to see what type of bath they had. The only time they document on a paper shower sheet was if the aides saw a skin issue, they would fill out the form and hand it to the charge nurse or the treatment nurse, otherwise they did their documentation in the EMR. The DON again said there were no paper shower sheets unless the resident had a new or current area, or skin problem. Residents Affected - Few Review of Resident #69's ADL Verification Worksheet dated 04/19/21 revealed: On 03/20/23 she was totally dependent on one staff member to shower her. On 03/20/23, 03/21/23, 03/23/23 and 04/18/23 she gave herself a shower. On 04/03/23 she received a shower with the physical help of one staff for transferring. She bathed herself and required the supervision of one staff for a shower on 04/19/21. On 03/19/23, 03/24/23, (there was nothing documented for 03/25/23), 03/26/23, 03/27/23, 03/28/23, 03/30/23, 03/31/23, 04/01/23, 04/02/23, 04/04/23, 04/05/23, 04/06/2304/07/23, 04/08/23, 04/09/23, 04/10/23, 04/11/23, 04/12/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23 and 04/17/23 she did not receive a bath or shower. An interview with Resident #69 on 04/20/23 at 2:39 PM revealed she was up in her wheelchair, dressed and well-groomed and stated she had finally received a shower yesterday. She had asked an aide, and was told she should ask for a shower, or remind them it was her shower day. Resident #69 stated she had been told they were to come to her and ask if she was ready on her shower days. During an interview with the DON on 04/20/23 at 3:41 PM she revealed if a resident asked for a shower/bath and it was not their scheduled day, they could still get it but only after the scheduled showers had been given or if staff were asked during a meal, then they could have one after they were done with the meal service. She said on their scheduled shower days they should not have to ask for a shower, staff should go get them when it was time for their shower. Review of the facility's policy and procedure, Showers undated revealed, Each patient will be offered a shower and/or bed bath at a minimum of three times a week. 1. Upon admission, the patient will be assigned a shower schedule according to the facility's shower policy. 2. On the patient's assigned shower day, the facility staff will offer a shower and/or bed bath to the 676472 Page 4 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0677 patient. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Few The patient has the right to refuse his or her shower. In the event the patient refuses, the charge nurse will notify the responsible party and document the refusal in the medical record. 676472 Page 5 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

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, the comprehensive person-centered care plan, the resident's goals and preferences for one of four residents (Resident # 71) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident # 71 had physician orders for oxygen via nasal canula which was administered by the facility. The facility failed to ensure Resident # 71 had physician orders for bipap machine (a type of ventilator that helps people with respiratory disease breath during sleep) which was administered by the facility. The facility failed to ensure Resident # 71's oxygen humidifier was changed weekly per facility policy. These failures could affect residents by causing residents who required respiratory care to have a diminished quality of life and complications with respiratory care. Findings included: Review of Resident # 71's face sheet, dated 4/20/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), chronic and acute respiratory failure. Review of Resident # 71's MDS, dated [DATE], revealed the resident was receiving respiratory treatments and had shortness of breath or trouble breathing when lying flat. The MDS indicated Resident # 71 had a BIMS score of 14 meaning she had little to no cognitive impairment. Review of Resident # 71's Progress note, dated 4/17/23 written by Nurse Practitioner (NP) revealed obstructive sleep apnea (OSA) and chronic respiratory failure were listed under Active Medical Problems. Review of Resident # 71's admission note written by LVN D on 4/03/23 at 9:39 PM indicated the resident was on Oxygen at 2-3 L continuous and daughter accompanied, brought personal bipap. Review of Resident # 71's nursing progress note, dated 4/04/23 at 4:05 AM written by LVN E indicated .pt tried new cpap and struggled with feeling claustrophobic with on, she wore for approx 3 hours then pt removed and wanted o2 back on and will attempt again every night til she feels comfortable to wear throughout the night . Review of Resident # 71's physician orders on 4/18/23, 4/19/23 and 4/20/23 revealed there was no order for oxygen via nasal canula nor was there any order for Bipap machine. Observation and interview on 4/18/23 at 11:50 AM revealed Resident # 71 on 2 liters of Oxygen via nasal canula in her room. The oxygen humidifier was dated 4/10. A Bipap machine was noted at Resident's bedside which Resident # 71 indicated she used it at night. 676472 Page 6 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 4/19/23 at 3:39 PM with DON revealed the facility did not have a policy regarding resident supplied medical devices. The DON stated the residents needed to have orders in place even if they brought in their own equipment so that the facility can know who their doctor is and follow up to see why they needed that item. Observation and interview on 4/20/23 at 10:31 AM revealed Resident # 71 seated in her wheelchair on O2 via nasal canula with the oxygen humidifier dated 4/10. The humidifier barely had any water left in it. Bipap machine was noted on bed stand. Resident # 71 stated the nurse checked her oxygen machine once in a while to make sure the setting was right and at night the nurse helped her get the head piece on for the bipap. Interview on 4/20/23 at 10:37 AM with RN F, revealed Resident # 71 was on Oxygen continuously and wore a bipap at night. She stated the night shift changed the tubing and humidification weekly. She stated there should be a physician's order for the oxygen. She stated if a resident came with something new, they would have to have an order first before facility staff started to touch the equipment. Interview and record review on 4/20/23 at 10:47 AM revealed RN F looked up Resident # 71 orders on her computer and stated she did not see orders for oxygen nor for the bipap. Interview on 04/20/23 at 10:50 AM with RN F, while surveyor showed the RN the oxygen humidifier and tube in Resident #71's room, revealed RN F stated she saw the date 04/10 (which was over a week ago) on the oxygen humidifier along with the low water level. She stated the oxygen humidifier would suck in dry air into the resident's nose if the sterile water was used up. Interview on 04/20/23 at 10:56 AM with ADON G, while surveyor showed ADON G Resident #71's oxygen humidifier, revealed ADON stated the sterile water in the oxygen humidifier was empty. She stated she changes the oxygen humidifier out every Friday and last Friday (4-14-23), she was unavailable, so she asked the nurse on her cart to change it. Interview on 04/20/23 at 11:28 AM with the DON revealed Resident #71's oxygen machine would still work even with no water in it, however, there would be no humidity. The DON revealed she did see that there were no orders for the BiPAP and oxygen machine. She stated the orders were in there now. The DON stated the person who entered Resident #71's admission orders should have entered orders for the BiPAP and oxygen when the resident admitted . Resident admitted from the hospital, and it was on the nurse's initial assessment notes that Resident #71 be on continuous oxygen, so it was missed. She stated normally it is the nurse that receives the admission that enters the orders. The resident initially did not come in with BiPAP orders. She stated the reason they did not enter the orders for the BiPAP was because the family could not say where the BiPAP came from. The facility did not know if the BiPAP was truly Resident #71's or not. The DON stated they tried to wean Resident # 71 off the oxygen but were unsuccessful. The DON stated the resident's oxygen levels were fine (between 95 and 98) with the oxygen on. The DON stated it was the facility's policy that if a resident came in with an oxygen machine and the resident was using it, there should be an order for it. Interview on 4/20/23 at 1:54 PM with LVN D, revealed she worked evenings with Resident # 71, and she helped her put on the bipap at night. Phone interview on 4/20/23 at 2:34 PM with NP revealed she did not realize Resident # 71 had a bipap in her room. NP stated neither herself nor the doctor (MD) ordered the bipap. The NP was not 100 percent sure if Resident # 71 needed the bipap, however she stated she did need the oxygen. NP stated 676472 Page 7 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was not sure if Resident # 71 had sleep apnea, however people with sleep apnea needed a bipap machine at night. NP stated she had not looked at Resident # 71's chart prior to returning surveyor's call. Interview on 4/20/23 at 4:20 PM with LVN H revealed she was one of the 3 MDS nurses. LVN H stated there were no orders for the oxygen or bipap and that is why it did not trigger the CAA on the MDS. LVN H stated that had she completed the MDS for Resident # 71 she would have updated the care plan and informed the DON that there were no orders so that the DON could follow up. LVN H stated there should have been an order in the chart for the bipap and the nurse should have been signing off on it if it was being used. LVN H stated normally everything was consistent: the orders, the MDS and the care plan. Review of the facility's Patient Care Management System Medications policy, dated November 2017, reflected the following: Upon admission (including readmission) of each Patient/Resident, the physician's orders for the Patient/Resident must be reviewed and reconciled by the Charge Nurse and the Director of Nursing or his/her designee for accuracy in the Electronic Medical Record. Review of the facility's Protocol for oxygen administration policy, updated March 2019, reflected the following: oxygen tubing, cannulas, nebulizer tubing's and face masks will be changed weekly and as needed. 676472 Page 8 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Many 1. The facility failed to ensure food items in the refrigerator and freezer were dated, labeled, and not expired. 2. The facility failed to ensure dishes and cookware were washed in the dishwasher with the appropriate sanitation procedures. These failures could affect residents by placing them at risk for food-borne illness. Findings include: 1. Observation and interview on 04/18/23 at 8:28 AM with the Dietary Manager (DM) revealed the following food items in the refrigerator, as identified by the DM: - Three containers of ranch dressing, with one opened and used. All three containers had an expiration date of March 2023. - One container of Ken's chicken dipping sauce, opened 03/23/23 with an expiration date of July 2022. - One bag of dill, undated, unlabeled, and exposed to air. - One bottle of cocktail sauce, opened 04/06/23 with a printed label from US foods on top of the bottle indicating expiration date was 04/03/23. - One container of garlic, opened with a best used by date of 04/09/23. - Three containers of Dijon mustard, with one container opened 03/27/23. All three containers had the same expiration date of 03/06/23. The DM stated all the expired foods must have come in expired. She stated she and the kitchen staff were responsible for checking the expiration dates. For the bag of dill, the DM stated the date was on the box when they took the bag out of the box. She stated it did not need to be sealed as the bag needed to be breathable. The DM stated they have been having problems with US Foods such as US Foods would not bring invoices and would just come in to drop the food and immediately leave. She stated US Foods is their only food supplier. 676472 Page 9 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0812 Observation and interview on 04/18/23 at 8:45 AM with the Dietary Manager revealed the following food items in the walk-in freezer, as identified by the DM: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Many One bag of frozen, opened French fries, undated, unlabeled, and exposed to air. One box full of frozen milk cartons all with an expiration date of 04/06/23. There was no date of when the frozen milk would need to be consumed by. One bag of frozen chicken breast, opened and exposed to air. The Dietary Manager stated she only used the individual milk cartons for dialysis residents. She would freeze the milk as soon as it came in and would thaw it overnight for dialysis residents to have cereal early in the morning before leaving for dialysis. Interview on 04/18/23 at 2:06 PM with the Admin revealed he had spoken to US Foods and the dates printed on the bottle are manufacturer dates, not expiration dates. The US Foods representative stated they had 6 months from the manufacturer date before the product expired. He stated the representative would send paperwork that stated that. The Administrator stated the date written on top of the container was the date the product was received. Observation on 4/18/23 at 4:06 PM revealed the expired items were no longer in the refrigerator. There were 3 of the expired milk cartons in a Ziploc bag thawing in the refrigerator. The box of expired frozen milk cartons was still in the freezer. Observation and interview on 04/18/23 at 4:08 PM with the Registered Dietitian (RD) revealed when she saw the expired milk in the refrigerator, she had the kitchen staff throw it out. She stated it was not acceptable and they could not use the expired milk, regardless of if they were frozen, since there would be no way to tell if the milk expired or not once thawed. They would have to go with the expiration date on the label. Record review of product detail sheets from US Foods, dated 4/18/23 revealed the food items had a shelf life of 180 to 210 days from the manufacturer date which was on the bottles of the dressings and sauces. Ken's Chicken Dipping Sauce had a shelf life of 210 days. The earlier observation revealed the manufacturer's date was July 2022. This item was received from US Foods on 3/23/23 per the date written on the top of the bottle. Therefore 243 days had already passed from 8/01/22 to 3/31/23, signifying this product was expired. 2. Observation on 04/19/23 at 11:35 AM of the low-temperature dishwasher revealed Nutrition aide (NA) was washing dome lids in the dish machine. Review of dish machine log for April 2023 revealed the dishwasher was last checked on 04/19/23 with no concerns. 676472 Page 10 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of manufacturer details on the dishwasher revealed minimum rinse temperature 120 degrees Fahrenheit and minimum chlorine PPM 50. Observation on 04/19/23 at 11:41 AM of the dishwasher revealed the temperature was up at 135 degrees Fahrenheit with a rinse temperature of 134.2 degrees Fahrenheit. Residents Affected - Many Observation and interview on 04/19/23 at 11:44 AM of the dishwasher with Nutrition Aide revealed NA used a quat test strip to check the chlorine. He held it up to the scale with the colors and stated it was showing the right amount of chlorine. The quat test strip did not reveal any changes to the color of the strip and did not match the color that was on the scale. Surveyor asked NA if he saw a difference from the tip of the strip that was dipped in the sanitizer compared to the end of the strip that was not dipped. He stated he did not see a difference. Observation and interview on 04/19/23 at 11:50 AM with the DM and the RD revealed the test strip was expired. The RD asked the DM for another box of test strips. The DM pulled out another test strip pack, which was the same for the quat sanitizer, and asked the RD where she could find the expiration date on the strip box. The DM stated last week the manufacturer was out of stock of the pellets that go on top of the dishwasher for the sanitizer so last week, [Contract Vendor] came to provide the alternate solution, which was a liquid solution for the sanitizer. Observation and interview on 04/19/23 at 11:52 AM with the DM and the RD revealed the DM checked the dishwasher with the chlorine strip test, which was the correct test strip. The test strip darkened but did not get dark enough to get to 50 PPM. The DM and RD insisted it was at 50 PPM. Observation and interview on 04/19/23 at 11:58 AM with the DM and RD revealed the dishwasher was run again. The DM tested it once more. Surveyor observed PPM to be between 35 to 40 PPM. DM insisted it was at 50. Observation on 04/19/23 at 12:00 PM with two other surveyors revealed the same test strip was at between 35 to 40 PPM. It was not dark enough to reach 50 PPM. Interview on 04/19/23 at 12:06 PM with the Admin and DON revealed the Admin and DON agreed the test strip did not appear to be at 50 PPM when shown the test strip against the scale. Observation and interview on 04/19/23 at 12:07 PM of the dishwasher with the DM, Admin, DON, and two other surveyors revealed the dishwasher was run again. The DM tested the dishwasher with the chlorine test strip and stated it was lighter than it was when she had checked earlier, which was inconsistent, to when she insisted the strip maintained at 50 PPM. The test strip appeared lighter than the last time the dishwasher was checked at about 10 PPM. Observation on 04/19/23 at 12:12 PM revealed the Nutrition aide started using the 3-compartment sink to sanitize the dome lids he was cleaning with the dishwasher earlier. The DM checked the sanitizer concentration of the 3-compartment sinks, which was at 200 PPM, matching the manufacturer instructions. Interview on 04/19/23 at 12:31 PM with the RD and DM revealed they did not say the test strip was expired, but that it was the wrong kind, which contradicted what they had stated prior. They stated they would hand wash the dishes until the technician (Tech) fixed the dishwasher. 676472 Page 11 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 04/19/23 at 12:54 PM with the Tech revealed he comes once a month to check the dishwasher but that the facility would call him if they had an issue. He revealed they could not get the pellets to the facility and had a temporary fix by putting some liquid sanitization in the dishwasher about a week ago on 04/14/23. The Tech stated he believed the straw that goes into the chemical bottle did not go all the way in, so it did not suck up enough of the chemical and sucked up air in the line instead. He stated the chemical had probably gassed off a bit, which indicated the chemical was a little weaker than normal. If the chemical was low, the facility would just need to call him, as he did not like it if the facility messed with the machine. He stated it was the facility's job to test the machine daily and if there was a problem to call him. The tech added that the facility did have a work around and could pour additional sanitizer in from the top if the concentration was not strong enough. Interview on 04/19/23 at 4:30 PM with the Administrator revealed the technician changed the chemical bottle and was now consistent with the manufacturer instructions. He stated the risk of not measuring the sanitation levels properly was residents could get sick from dishes being under or over-sanitized. Review of the Dish Machine Temperature log for April 2023 revealed the sanitizer PPM was 100 in the morning on 4/19/23. The log revealed the wash cycle temperature, rinse cycle temperature and sanitizer concentration were checked 3 times daily and there were no concerns with the documentation for April 2023. Interview on 04/20/23 at 9:51 AM with the NA revealed he normally did the dishes in the morning. He would check the sanitation level on his shift right before doing dishes and stated he was using the wrong strip yesterday. The correct strip, which was the chlorine strip, is supposed to turn dark purple with the PPM at 100. He stated it was important to make sure the sanitation level was correct before using the machine, so residents don't get sick. The NA stated that he was the one who checked the sanitizer concentration for the machine in the morning on 4/19/23 with the correct test strip and it was at 100 PPM. Interview on 04/20/23 at 9:58 AM with the DM revealed freezing milk was not best practice even though it was frozen before the expiration date since no one would know if the milk was expired or not. It could make the resident sick if the milk was spoiled. She stated it was important to seal food products to ensure there were no contaminants. Dating was important to keep track of the shelf life of the food products. Labeling was important to know what the product was if it was not in the original container. The DM stated the bag of dill should have been labeled when removed from its original container. She stated the French fries should have been dated, labeled, and placed in a Ziploc bag. The DM also revealed the sanitizer is the most important part of the dishwasher as the kitchen had a low-temperature dishwasher. The sanitizer killed the bacteria. It was important to ensure the correct concentration, so the residents do not get sick. Observation on 04/20/23 at 10:14 AM revealed the NA manually added sanitizer to the dishwasher with a syringe. He tested the machine with a chlorine strip and it was at 100 PPM, which matched the manufacturer instructions. Policy titled Food storage dated March 2009; Revised 3/2019 All food items should be dated with the received date, unless labeled with a readable label from the food vendor Left over food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded. 676472 Page 12 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0812 Frozen foods .c. Foods should be covered, labeled and dated. Level of Harm - Minimal harm or potential for actual harm Policy titled Dish Machine Temperatures All dishes, utensils and pots will be sanitized through the dish machine using the proper water temperatures and sanitizer Procedure 1. Dietary staff will check the water temperature and level of sanitizer of the dish machine before any food containers are washed. Residents Affected - Many The policy continued to list what should be done if the water temperatures are not correct, they should stop and inform the Dietary Services Manager and the Maintenance Director, but the policy did not state what should be done if the sanitizer level is incorrect. Review of the U.S. Public Health Service Food Code, dated 2017, reflected: 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A). (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section . 4-302.14 Sanitizing Solutions, Testing Devices. Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and Annex 3 - Public Health Reasons/Administrative Guidelines 502 2. Too much sanitizer in the final rinse water could be toxic. 676472 Page 13 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Staff (CNA A) of three staff observed caring for a COVID positive resident and one staff (MA B) of three staff observed during medication pass for infection control in that: Residents Affected - Some 1. CNA A failed to wear the recommended PPE when answering a call light for Resident #15, a COVID positive resident on isolation. 2. MA B failed to prevent contamination of the cap and eyedrop bottle for Resident #33. MA B cross-contaminated her medication cart by placing Resident #33's eye drop bottle, and nasal spray box on her bedside table then into the cart. MA B Used contaminated gloves to place eye drops into Resident #17's eyes. MA B Failed to use proper hand hygiene before administering each residents' medications. MA B failed to follow proper protocol for hand hygiene by not washing her hands after three times of using sanitizer. These failures could affect all residents by causing cross contamination and placing them at risk for exposure to a contagious disease, infection, and possible hospitalization. Findings include: 1. Resident #15's Face sheet dated 04/20/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hypertension, congestive heart failure, multiple sclerosis, chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), anxiety disorder and major depressive disorder. Review of her COVID-19 Antigen test dated 04/12/23 revealed she was symptomatic with congestion and a cough, and the result was positive. An interview with the DON on 04/18/23 at 8:40 AM revealed they had one COVID positive resident (Resident #15) who had been there during routine testing and tested positive on 04/12/23. After testing positive Resident #15 had informed the facility that her husband had not been feeling well. The DON also said she was coughing and had very thick sputum and was supposed to have gone home on the 12th but was now on isolation in the very last room on the 800 hall. An observation and interview on 04/18/23 at 11:36 AM revealed room [ROOM NUMBER]'s call light going off, CNA A came out of a different room, used hand sanitizer, and went down to room [ROOM NUMBER]. CNA A donned a gown, gloves, and had an N-95 mask on and went into Resident #15's room and shut the door. At 11:40 AM, CNA A came out of the room, doffed gown, gloves, used sanitizer on her hands. She then changed masks, at 11:42 AM CNA A was walking by and the surveyor asked her if she had worn goggles or a shield and she said she had just worn a mask and gown, then asked, Should I have worn a 676472 Page 14 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shield? Surveyor said the last she had heard they were supposed to. CNA A said Well, I have to go back in so I will wear one then. Surveyor asked if there were shields available and she said yes. At 11:49 AM CNA A went back and donned gown, gloves, a face shield, and had an N95 mask on and went back into Resident #15's room. During an interview with CNA A on 04/20/23 at 2:00 PM she revealed the PPE she was taught to use in COVID positive rooms was gloves, gown, face shield or goggles, and an N95-mask. CNA A also stated a face shield or goggles were important to prevent spreading the infection and to protect herself from 2. An observation on 04/19/23 at 8:46 AM, MA B had already prepared Resident #33's medications and because she was in the restroom, waited until she got out to take the medications into her room. At 8:53 AM, MA B gloved, opened one of the eye drops and placed the lid on the top of her medication cart, open end down (contaminating the top). She then picked up all of Resident #33's medications, knocked and put them (2 eyedrops, one in a bullet and one in a bottle, the nasal spray box and two portion cups) on Resident #33's bedside table. MA B gloved, took the bottle of nasal spray out of its box, rolled it back and forth to mix it and gave Resident #33 one spray in each nostril then put the bottle back in its box. Then without performing hand hygiene or changing gloves, MA B picked up the eye drop in bullet form (a small plastic vial of sterile eye drops), pulled the top off, pulled Resident #15's left lower lid down and dropped 1 drop in her eye. MA B threw the rest away as they came in small single use bullets, poured the PO medications into the portion cup with vanilla pudding, mixed them, and gave them to Resident #33 in two spoonsful. Resident # 33 took them without any problems. MA B then without performing hand hygiene or changing gloves and after 5 min from first eye drop, took the next eye drop pulled Resident #33's left eyelid down and dropped one drop in. MA B then took the nasal spray box and without sanitizing it placed it into the drawer of her medication cart (contaminating her cart), picked the eye drop lid up from the cart and without sanitizing it, put it back on the eye drops (Contaminating the bottle) and placed them into her medication cart (contaminating her cart). An observation on 04/19/23 at 11:38 AM revealed MA B prepared Resident #8's medications. MA B took all the medications to include a bottle of eye drops and placed them on her overbed table. After giving her the by mouth medications and without performing hand hygiene, she donned gloves and pulled her right eyelid down and placed a drop in and then pulled the left eyelid down and placed a drop in. MA B then put the bottle of eye drops back in its package and placed it in her cart without sanitizing the bottle. An observation on 04/19/23 at 11:50 AM revealed MA B opened her cart, looked through Resident # 17's medications, prepared her medications, took medications to include a bottle of eye drops and placed them on Resident #17's bedside table (contaminating the eye drop bottle). MA B gloved, went over, and turned the light on with her right gloved hand (contaminating her glove), came back to the Resident and without changing gloves or performing hand hygiene, used her right hand to pull Resident #17's right eye lid down and placed one drop in it, then pulled her left eyelid down and placed one drop in it. MA B gave Resident #33 her other medication in a portion cup with a sip of water, doffed her gloves, went back to her medication cart and put the eyedrop bottle back in the cart without sanitizing it. She then sanitized her hands. During observations of medication pass by MA B on 04/19/23 from her first resident at 11:24 AM to her next at 11:30 AM, to the next at 11:38 AM, to the next one at 11:50 AM and the last one at 12:00 PM MA B only sanitized her hands one time before going into the room and administering the 676472 Page 15 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medications. She always used sanitizer after she had completed the medication pass to a resident before preparing the next residents' medications but not before administering the medications to the next resident. MA B also never washed her hands with soap and water during the medication pass and only used sanitizer on her hands. During an interview with MA B on 04/20/23 at 1:44 PM she revealed she should have put the lid to the eye drops back in the bag, so it would not get contaminated. She also said she should have wiped with sanitizer cloths, the nasal spray box, the top of the eye drop bottle, and the bottle of eye drops before putting them back into their containers and in the med cart. MA B said she should have done this, so nothing got contaminated and so do not have cross contamination from her to the cart. When asked how often you were supposed to wash your hands with soap and water, she said she was supposed to use sanitizer 3 times then wash her hands with the next time, to prevent cross contamination and prevent spreading infections. [NAME] also said she should have turned the light on before donning gloves or she should have washed her hands and/or changed gloves before administering the eye drops because she contaminated her gloved hand so cross contaminated the eye lid possibly causing an infection. She said she was taught to wash or sanitize her hands before and after care, after touching something/someone and she should have taken off her gloves or changed them and washed her hands before touching the resident's eyes. During an interview with ADON C on 04/20/23 02:06 PM he revealed his staff should clean the bottle/box before replacing it into the medication cart. When she took the eyedrop lid off, she could hold it in your gloves and wipe the top with a sani cloth after use. She should not have set it on top of cart because infection control and cross contamination. ADON also said they were to use sanitizer three times then wash your hands. He also said if he used it three times with one resident, he washed his hands because they get sticky and could cause possible cross contamination. Should not have turned the light on with gloved hand and then used them to pull an eye lid down but should have performed hand hygiene and changed gloves before using the eye drops. ADON C also said his staff should wear goggles or a shield when going into a COVID positive room or any room with the resident on droplet isolation. He also said we train them that way because it was important for droplet precautions and trying to prevent transmission to ourselves and other residents. During an interview with the DON on 04/20/23 at 3:32 PM she revealed you could hold the lid to the eye drops in your other hand, so the inside doesn't touch anything and then contaminate the bottle. She said her staff should wear an N-95 mask, face shield or goggles, gown, and gloves to go in and assist a COVID positive resident. They are important to ensure they do not spread it to other patients and to keep it confined. When informed of what the CNA had asked about (Should she have worn a face shield) the DON said the box of shields were right there on top of the PPE bin outside the residents door and there was a sign on the door that tells them what to wear. The DON also said the MA should have turned the light on when entering the room, then given the medications, then gloved and administered the eye drops. She also stated her staff should have used the sanitizer three times and then washed their hands. Review of the facility's policy and procedure, CORONAVIRUS COVID-19 PROTOCOLS' dated October 04, 2022, revealed the following: 4. Utilize appropriate personal protective equipment (PPE) for certain patient care activities such as: a. Caring for Covid positive individuals. Face Coverings and Masks: .All transmission levels: Face coverings and masks required during an outbreak. 676472 Page 16 of 17 676472 04/20/2023 Sundance Inn Health Center 2034 Sundance Parkway New Braunfels, TX 78130

F 0880 Review f the facility's policy and procedure Infection Control dated November 2017 revealed the following: Level of Harm - Minimal harm or potential for actual harm 1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment. Residents Affected - Some Review of the facility's policy and procedure, Handwashing/Hand Hygiene dated August 2019 revealed the following: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a.b. Before and after direct contact with residents; c. Before preparing or handling medications; d. i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. This policy further reflected, Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 676472 Page 17 of 17