Health inspection·March 28, 2023

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MARs at this time revealed the Amlodipine was to be hold if BP was less than 120. Amlodipine was given to the resident. During an Observation on 03/27/2023 at 10:20 AM, CMA A administered Lidocaine 4 % Patch to Resident # 11. Resident #11's patch was missing and was not removed at time of administration. Medication order from the doctor stated Lidocaine patch to be removed everyday at 8:59 AM and applied at 9:00 AM. CMA A applied the new patch and did not investigate what happened to the prior patch. Resident # 11. Resident #11 was unable to be interviewed due to cognitive impairments. During an Interview with CMA A on 03/28/2023 at 9:51 a.m. she reported that she gave the Amlodipine because she did not look at the med order thoroughly. CMA A stated that it is facility policy to look at the MAR orders before administering medication. CMA A stated that Resident #11 can experience adverse effects when taking blood pressure medication with blood pressure below 120 such as getting dizzy and being at risk for falling. During an Interview with CMA A on 03/28/2023 at 9:55 AM she reported that the Lidocaine patch was supposed to be on Resident #11 but must have gotten removed prior to the new patch being administered. CMA A could not provide an answer for what happened to the patch, when or where it had been removed from the resident. When asked what the facilities policy is regarding administering medications, she stated that staff is supposed to follow the MAR and if there are any confusion to notify the nurse. CMA A stated that incomplete therapy or failure to remove patch per med order can lead to rResident # 11 having uncontrolled pain. During an interview with the DON on 03/28/2023 at 10:30 A.M. she reported that medication orders should be followed when staff is performing med pass. The DON stated that medication errors can happen when med orders from the doctor are not followed. The DON stated that if blood pressure falls outside doctors' parameters for administration CMAs are supposed to notify the nursing staff so they can perform assessments. The DON stated that if the lLidocaine 4 % patch was to be applied that the previous patch should be removed beforehand according to the doctor's med order. The DON stated the CMA should have immediately found out what happened to the patch and/or notify the nurse as soon as they are were made aware the patch was removed. The DON stated that adverse events such as bradycardia, dizziness, falling, and lethargy can occur with this medication error. During an interview with the Admin on 03/28/2023 at 03:00 P.M. he reported that medication orders should be followed when staff is performing med pass. He also stated that in services are done monthly by the consulting pharmacist with all staff members who perform med passes. The Admin stated that medications for blood pressure can cause dizziness and falls when not followed according to the doctors' orders. The facilities policy is to administer medications according to the medication order. The Admin stated facilities policy regarding patches are to check residents for patch removal before applying a new one and if not there to immediately notify a nurse so they can assess for pain. The Admin stated that when Lidocaine patches are not being applied per doctors' orders than Resident # 11 can experience uncontrolled pain. Findings for Resident # 27 included: Record review of Resident #27's face sheet dated 03/27/2023 revealed an admission date of 07/26/2022 and diagnoses of Essential Hypertension, Chronic obstructive pulmonary disease, Type 2 Diabetes, Dysphagia(difficulty swallowing), Chronic Obstructive Pulmonary Disease(long term lung disease), and Gastro Esophageal Reflux Disease(heartburn). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Record review of rResident #27's Physician's order (03/27/2023) and MARs for March 2023 revealed the following medications: Level of Harm - Minimal harm or potential for actual harm 1. Pepcid 10 mg PO (06:00 a.m.-10:00 a.m.) Residents Affected - Some Record review of rResident #27's MAR (03/27/2023) revealed that CMA A did not administer Pepcid 10 mg. Record review of Resident #27's MAR ( 03/27/2023) revealed that Resident #27 Received 20 mg Pepcid on 03/26/2023 During an observation on 03/27/2023 at 09:51 a.m., CMA A realized Resident #27's Pepcid dosage was wrong. CMA A looked at the order and decided not to administer the medication after seeing the order. Prescriber ordered 10 mg, but facility had 20 mg on stock. During an interview on 03/28/2023 at 10:05 a.m., CMA A reported that Resident #27's morning medication of Pepcid had the wrong dose on stock. CMA A stated that the facility needed to order the right dose. CMA A stated that facility policy is to administer medication per protocol, so she held the dose and notified the nurse regarding the wrong dose being on stock. CMA A stated that the facility needed to order the right dose. CMA A stated that facility policy is to administer medication per protocol, so she held the dose and notified the nurse regarding the wrong dose being on stock. The DON is supposed to ensure that the correct medications are ordered and stocked at the facility. During an interview on 03/28/2023 at 10:05 a.m., the DON stated that Pepcid 10 mg was supposed to be given. Explanation for why the wrong dose was on stock was not clear. When DON was asked why the correct dose was not provided she stated that Their drug delivery system has many glitches and needs to be fixed. The DON stated that medication not being provided to Resident # 27 can cause stomach pain. During an interview on 03/28/2023 at 03:00 P.M with the Admin, Pepcid 10 mg was supposed to be on stock. No explanation was provided for why wrong dose was stocked. The Admin stated that facility policy is to follow the MAR/physician orders. The Admin stated that not providing Pepcid to rResident #27 can increase the risk of adverse events such as stomach pain. Findings for Resident # 20 included: Record review of Resident #20's face sheet dated 03/27/2023 revealed an admission date of 10/03/2022 and diagnoses of Post-Traumatic Stress Disorder, Heart Disease, Essential Hypertension, Type 2 Diabetes, Unspecified Asthma, Chronic Obstructive Pulmonary Disease, and Gastro Esophageal Reflux Disease. Record review of rResident 20's Physician's order and MARs for March 2023 revealed the following medications: 1.Depakote 250 mg PO not given (06:00 a.m. - 10:00 a.m.) 2. Singular 10 mg PO not given (06:00 a.m. - 10:00 a.m.) 3.Protonix 40 mg DR PO not given (06:00 a.m. - 10:00 a.m.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of rResident #20's MAR (03/27/2023) revealed Depakote 250 mg PO, Singular 10 mg PO, Protonix 40 mg PO were not administered. During an observation on 03/27/23 at 12:15 a.m. CMA A could not locate Resident #20's medications of Depakote, Singular, and Protonix. CMA A was at the med cart searching Resident # 20's medication bag for the medications. Surveyor heard CMA A say that Some of Resident # 20's medications are not here I will not be able to administer them. During an interview on 03/28/2023 at 10:15 a.m., CMA A reported that Resident #20's Medications are packaged in 3 different ways from various pharmacies. CMA stated Some of his meds come in bottles from pharmacy and some come in blister pack and the rest come through our med port system through a paper slip. CMA A stated that she needed to go figure out where the medications that were missing are located. CMA A stated that the way Resident # 20 medication is packaged makes it hard for staff to locate the medication. CMA A stated that the medication was later found and given to the resident. No time of medication administration was provided to the Surveyor. When asked what time CMA A could not provide the information except that it was after noon time.CMA A stated that the charge nurse found them soon after CMA A gave the medications to Resident # 20. CMA A stated that per facilities policy, medications are supposed to be administered within 1 hour before and 1 hour after scheduled time. CMA A stated that by not receiving medications at the ordered time Resident # 20 can experience breathing issues, moody behavior, and stomach pain. During an interview on 03/28/2023 at 10:30 a.m., the DON reported that Resident #20's is packaged differently than other residents and that led to the confusion. The DON stated that facility policy for when med aides are out of medication is they are to communicate immediately to the nurse of or DON so medication can be reordered. The DON stated that by Resident #20 not receiving medications he can experience uncontrolled allergies, breathing problems, stomach pain, and mood disorder. During an interview on 03/28/2023 at 03:20 a.m., the Admin reported that if rResident #20's medications are not stocked it is the responsibility of the staff member administering meds to report it to the nurse. The Admin stated that by not receiving medications at the ordered time Resident # 20 can experience breathing issues, moody behavior, and stomach pain. The Admin stated that it is required by policy for medications to be delivered within 1 hour before and 1 hour after scheduled time. Record Review of Facility policy dated 11/2022 listed the following rules: 1. Review Mar to identify medication to be administered 2. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physicians' prescribed parameters 3. Administer medication as ordered by the in accordance with manufacturer specifications 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Administer medication within 60 minutes prior to or after scheduled time unless otherwise noted by the physician Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 52 of 52 residents reviewed for food sanitation/storage. Residents Affected - Some The facility did not store six boxes of fruits in a dry storage area. The facility did not store chemicals away from food in the kitchen This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 3/26/23 at 8:13 am, underneath one of the three food preparation tables, there was a bucket filled with white-colored fluid sitting between two boxes of bananas and a box of white onions. On the left side of the bucket, the box of white onions was open. On the right side of the bucket, the two boxes of bananas were stacked on top of each other. The top box of bananas was open. During an interview on 3/26/23 at 8:20 am, [NAME] A said the white-colored fluid in the bucket was a mixture of cleaning solution and water. [NAME] A said the bucket filled with the mixture was temporarily sitting underneath the food preparation table. [NAME] A said the bucket was sitting underneath the food preparation table since she began her shift. [NAME] A explained she used the bucket filled with the mixture to wipe down the food preparation table. [NAME] A said she was going to move the bucket to another area. During an observation on 3/27/23 at 11:39 am, underneath the same food preparation table, a bucket filled with clear fluid and a white towel was sitting between two boxes of bananas. One the right side of the bucket, the box of bananas was open. On the left side of the bucket, the box of bananas was closed. A white onion in a clear plastic tray was sitting on top of the closed box of bananas. During an interview on 3/27/23 at 11:45 am, the DM said the clear fluid in the bucket was a mixture of cleaning solution and water. The DM also said the bucket contained a white towel. The DM said she did not know why the bucket was in between two boxes of bananas. The DM explained she placed a bucket filled with cleaning solution and water underneath each food preparation table because she was taught this practice during her past employment working in Assisted Living Facilities. The DM said she was not sure if having a bucket filled with cleaning solution, water, and a white towel between or next to fresh produce would have an adverse consequence on residents' health. During an interview on 3/28/23 at 12:09 pm, [NAME] B said she was trained on food safety and maintenance. [NAME] B said the trainings were reviewed two or three times every month. [NAME] B said there were also meetings each month that reviewed food safety and maintenance. [NAME] B said the cooks and dietary aides conducted kitchen maintenance. [NAME] B said she was told by the DM to store a bucket with a mixture of cleaning solution and water underneath each food preparation table. [NAME] B said she was also taught this practice by other DMs during her previous employment at other nursing facilities. [NAME] B explained the bucket was kept underneath the food preparation table to ensure staff were cleaning the food preparation tables after using them. [NAME] B said the cleaning solution in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the buckets were changed out every four hours or when it appeared disgusting. [NAME] B clarified that disgusting meant the water was a dark color and had a foul odor. [NAME] B said she did not know if having a bucket filled with cleaning solution, water, and a white towel sitting between or next to fresh produce would have an adverse consequence on residents' health. Record review of the 2015 Oasis 146 Multi-Quat Sanitizer posting revealed instructions and testing. The posting revealed the cleaning solution was an EPA-registered sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and ware was effective against foodborne organisms. The posting instructed to use the sanitizer on surfaces of equipment for a period of not less than one minute or until dry. During an interview on 3/28/23 at 12:33 pm, DA said he was trained on food safety and maintenance. DA said he cleaned and stored the dishes in the kitchen. DA said the dishes were cleaned using a cleaning solution. DA said the cleaning solution was not safe to consume. DA said a resident could become ill if he/she consumed the cleaning solution. DA said he was aware there were buckets filled with the cleaning solution, water, and towels underneath each food preparation table. DA said he was trained this practice by the DM. During an interview on 3/28/23 at 4:29 pm, the DM said she was trained on foodborne illness, food safety, and maintenance. The DM said she trained staff when they were hired and monthly. The DM said she was aware the buckets filled with cleaning solution, water, and towels were underneath the food preparation tables. The DM said the buckets filled with cleaning solution, water, and towels were changed out every two hours, whenever they were used to clean the tables after preparing meat, and as needed. The DM said the buckets were labeled whenever the cleaning solution, water, and towels were changed out. The DM said she learned the storing practice from previous employment. The DM said she was not sure if the practice was compliant at skilled nursing facilities and nursing facilities. The DM said she was not sure what kind of cleaning solution was in the buckets. The DM said she believed the cleaning solution was safe for residents to consume . The DM said she did not know what was in the cleaning solution. The DM said she could not answer if having a bucket filled with cleaning solution, water, and a white towel sitting between or next to fresh produce would have an impact on residents' health. The DM later said she believed the resident could die due to contamination. During an interview on 3/28/23 at 5:47 pm, the VP said the facility did not have a policy and procedure for buckets filled with the cleaning solution, water, and towels stored underneath food preparation tables. The VP stated, The practice was always done. Record review of Food Safety Requirements policy and compliance guidelines reviewed and revised on 11/1/21 revealed the policy, definitions, explanation, and compliance guidelines. The policy stated, Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Contamination was defined as, The unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Food service safety was defined as, Handling, preparing, and storing food in ways that prevent foodborne illness. Foodborne illness was defined as, An illness caused by the ingestion of contaminated food or beverages. The policy's explanation and compliance guidelines stated, Food safety practices shall be followed throughout the facility's entire food handling process . Elements of the process include the following: Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . Additional strategies to prevent foodborne illness include, but are not limited to: Preventing cross-contamination of foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 development and transmission of communicable disease and infections for 2 of 3 residents (Resident #31 and Resident #204) reviewed for infection control Residents Affected - Few The facility failed to -ensure CNA G performed hand hygiene before assisting Resident #31 with meals. -ensure LVN M change gloves and perform hand hygiene during wound care for Resident #31 and Resident #204. This deficient practice could place the residents at risk for transmission and/or spread of infection. Finding included: Review of Resident #31's face sheet dated 03/28/23 reflected admitted to the facility on [DATE] with diagnosis diagnoses of DM (a condition which results in too much sugar in the blood), HTN (high blood pressure), and general muscle weakness. Review of Resident #31's annual MDS dated [DATE] reflected a BIMS of 11, indicating moderate cognitive impairment. MDS assessment indicated Resident #31 needs supervision and setup assistance with meals. Observation on 03/26/23 at 11:55AM revealed CNA G touched the corn bread with bare hands while placing butter for the Resident #31. The corn bread was on the tray with rest of the meals. CNA G was observed passing tray to the roommate of Resident #31 and did not perform hand hygiene prior to touching the corn bread. Interview on 03/26/23 at 1:51PM with CNA G revealed that she was aware of touching the corn bread and that she did not perform hand hygiene prior to assisting the resident. CNA G stated she did not realize to replace the corn bread for the resident at the time. CNA G stated an in-service on hand hygiene was conducted few months ago by the DON. CNA G stated the adverse effect could be contaminating the corn bread and could get the resident get upset over it. Observation on 03/27/23 at 1:36PM, revealed LVN M did not change gloves and did not perform hand hygiene between cleaning the wound and applying the cream onto the wound of Resident #31. Review of Resident #204's face sheet dated 03/28/23 reflected resident was admitted to the facility on [DATE] with diagnoses of hyperlipidemia (a condition in which there is high levels of fat particles in the blood), Dementia (loss of memory that interferes with daily functioning), TIA (a brief stroke-like attack that resolves within minutes to hours), and hypothyroidism (a deficiency of thyroid hormones). Review of Resident #204's admission MDS dated [DATE] revealed the assessments had not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Brixton at Horseshoe Bay 15101 West Fm 2147 Horseshoe Bay, TX 78657 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 completed at the time of review. Level of Harm - Minimal harm or potential for actual harm Observation on 03/27/23 at 2:38PM, revealed LVN M did not change the gloves and did not perform hand hygiene between cleaning the wound and applying the cream onto the wound of Resident #204. Residents Affected - Few Interview on 03/27/23 at 2:49PM, LVN M stated she did not realize that she did not change the gloves after cleaning the wound and before applying the cream to the wound. LVN M stated the adverse effect could be infection of the wounds. LVN M stated she had not received training on wound care but had in-services. Interview on 03/28/23 at 10:46AM, the DON stated not changing out the gloves between cleaning the wound and applying cream to the wound is not a safe practice and could lead to contamination and possibly infecting the wounds. The DON stated her expectation of the staff are to perform hand hygiene and wear clean gloves when touching resident's food while being assisted with meals. The DON stated adverse effect would be contaminating the food. Interview on 03/28/23 at 12:06PM, the ADMIN stated when going from dirty to clean during wound care, staff is to perform hand hygiene to prevent any type of infections. The ADMIN stated staff are given in-services on hand hygiene by the nursing management. The ADMIN stated hand hygiene should be performed prior to assisting residents with meals and if food is being contaminated, the food should be replaced for the resident. Review of facility's policy titled Hand hygiene dated revised on 11/20/23, reflected: all staff will perform proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745004 If continuation sheet Page 9 of 9