**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 4 residents (Resident #117) observed for infection control. The facility failed to ensure CNA B followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #117 on 05/05/2025. These failures could place the residents at risk for infection. Findings included: Record review of Resident #117's face sheet dated 04/24/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Septic Arthritis to the left knee (bacterial infection in the knee joint) Record review of Resident #117's MDS admission Assessment, dated 04/16/25, revealed that the resident had a BIMS summary score of 15, which indicated that the resident was cognitively intact. Further review revealed that Resident #117 required supervision and touch assistance with toileting. Record review of Resident #117's comprehensive care plan revealed that the resident had an infection related to a compromised immune system and the presence of pathogenic microorganisms. Interventions included proper hand washing using antibacterial soap before and after each care activity and maintaining sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter. During an observation on 05/05/25 at 10:21 AM, CNA B walked into Resident #117's room accompanied by CNA J. Both CNA B and CNA J washed their hands and donned (put on) their gown and gloves. CNA B performed catheter care on Resident #117, turned the resident to his right side, and wiped his buttocks three times. She removed the old brief, discarded it in the trash, and applied a new brief. CNA B used the same gloves and did not perform hand hygiene throughout the entire incontinent care process. They doffed (removed)their PPE and washed their hands. CNA B and CNA J thanked the resident and left the room. During an interview on 05/05/25 at 10:21 AM, CNA J said she was unsure why CNA B did not wash her hands or change her gloves while performing catheter care. She said the staff wereare in-serviced on washing their hands and changing gloves when going from dirty to clean. She said the risk of not washing hands and changing gloves during incontinent care could lead to cross contamination. She was unable to recall the last time she was in-serviced on infection control when performing incontinent care. During an interview on 05/05/25 at 10:38 AM, CNA B said she was supposed to wash or sanitize her hands after providing catheter care and when applying a new brief. She said the staff should remove gloves, wash/sanitize their hands, and apply new gloves when going from a dirty brief to a clean brief. CNA B said she realized that she had not changed her gloves and had used the same gloves during the entire process after she had completed incontinent care. She said she had a skill check off on infection control and was educated on hand-hygiene and incontinent care during on-boarding. CNA B said the risk of not changing her gloves and performing hand-hygiene could cause cross-contamination and infection. During an interview on 05/07/25 at 11:55 AM, the unit manager said she expected staff to follow standard precautions, and they should wash their hands before, during, and after providing incontinent/catheter care for all residents. She said the risk of not washing/sanitizing their hands could lead to cross-contamination and/or infection to all residents and staff. During an interview on 05/07/25 at 5:56 PM, the Quality Director said the staff should follow standard precautions and aseptic techniques when providing incontinent/catheter care. She said the staff should wash their hands before placing clean gloves on and wash hands before, during, and after all procedures. The Quality Director said the risk could be infection to other residents and themselves. She said she would be performing re-education and skills checkoff for infection control and incontinent care with all staff. Record review of the facility policy on Infection Control dated 11/2001 (Revised 6/2024) read in part .A. Standard Precautions--Standard Precautions combines the major features of Universal (Blood and Body Fluid) Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances)and applies them to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status. Standard precautions apply to: · blood, · all body fluids, secretions, and excretions regardless of whether or not they contain visible blood, · non-intact skin, and · mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a temperature range of 71°F to 81°F for 14 of 14 residents reviewed for exposure to high temperatures in the facility. -The facility air conditioning system had not been working adequately for up to two weeks. -The temperature of a common area (dining room) used by the residents was above 81°F. This failure placed all residents at risk for hyperthermia (elevated body temperature that could result in stroke or death). Findings Include: Observation on 06/27/2023 at 11:40 a.m. revealed the facility was a ground-floor wing of a multi-story hospital. Entry required walking through the main lobby and hallways. Observation during the walk revealed comfortable temperatures. Upon approaching the SNF section of the hospital, the temperature in the hallway became noticeably warmer. In an interview 06/27/2023 at 11:45 a.m. with the DON, she said the air conditioning problem was reported to HHS that morning (06/27/2023). She said the air conditioner had been repaired in the last two weeks because they were having trouble keeping the 1st floor cool in the areas where resident rooms were occupied with residents. She said no residents had been relocated to an area where the air conditioning was functioning. She said they were waiting for State Office to give permission. After the surveyor asked the facility to review its Emergency Plan that they started relocating residents. Observation on 06/27/2023 at 11:46 a.m. revealed a portable air conditioning unit was near the nurses' station. The thermostat on the unit read 64°F. The thermometer on the unit read 77°F. There was a total of five portable air conditioner units operating in the facility. One was at the nurses 'station, and four were in the hallway of the facility. There was one unit in the hallway by room [ROOM NUMBER], near the nurses' station. There were two units in the hallway near room [ROOM NUMBER], near the center of the hall. There was one unit in the hallway by room [ROOM NUMBER], the furthest occupied room from the nurses' station In an interview on 06/27/2023 at 11:50 a.m. with the hospital Director of Quality Management she said the air conditioner repair company would be at the facility on 06/29/2023. She said the hospital could accommodate the residents on the fourth floor of the hospital, which was currently vacant but equipped. She said she was concerned for the residents because the temperatures were expected to rise to the 100's same day. Observation and interview on 06/27/2023 at 11:55 a.m. with DM A revealed he had a hand-held infrared digital thermometer. During the coolest part of the day (morning) the following temperatures were obtained by DM A at approximately five feet above the floor: room [ROOM NUMBER] 80.2°F room [ROOM NUMBER] 80°F room [ROOM NUMBER] 79°F In an interview on 06/27/2023 at 12:10 p.m. the QC B said the residents would need to be relocated for approximately 1 week. She said the main air conditioners for the facility stopped working yesterday (07/26/2023) around 3:00 p.m. She said the portable units were brought in at that time. In an interview on 06/27/2023 at 12:21 p.m. DM A said the portable units were brought in at 5:30 p.m. the previous day (6/26/23). Observation on 06/27/2023 at 12:55 p.m. revealed residents were being transferred to the fourth floor of the hospital by facility direct care staff. In a meeting on 06/27/2023 at 1:05 p.m. with CNO C, QC B, DM A, the LSC surveyor, and the health surveyor, CNO C said the problems with the main air conditioner began about 2 weeks ago but they were able to move residents around. She said they were able to move residents around within the facility to keep them cool. She said yesterday (06/26/2023) was the first time they could not accommodate by rearranging residents. Observation and interview on 06/27/2023 at 1:15 p.m. revealed a family member visiting Resident #1 in their room. The family member said he was hot in the Resident's room. The Resident agreed. The family member said the news weather had reported hot days with temperature up to the 100s during the week. Observation and interview on 06/27/2023 at 1:35 p.m. revealed Resident #2 in his room. He had a box fan in his room. He said it was hot even with the fan on. He said the portable air conditioner units in the hallways did not cool the room. He said he arrived on 06/14/2023 (ten days ago), and it was hot in the facility then. He said he had not been moved to a cooler room. He said the temperature in his room seemed like 100 degrees in this hot city weather. Observation on 07/14/2023 at 2:18 p.m. with SHVT D revealed he used a facility hand-held infrared thermometer to obtain the temperature of the dining room. The temperature was out of the 71-81°F range. The temperature was 81.4°F at approximately five feet above the floor. Record review of Houston's Weather dated 6/27/23 located at https://weather.com/weather/monthly/l/Richmond+TX?canonicalCityId=14d44e5b5730110f5a865c606dc0defff4abdf0c89fb7ccdb0f881987bef9730 read in part the high temperatures from 06/27/2023 to 07/14/2023 in Richmond Texas ranged from 86 °F to 101 °F, with the average high temperature being 98 °F. The high temperature on 06/27/2023 was 101 °F . Record review of the facility Emergency Operations Plan 2021-2023 (page 6) read in part . An Emergency is an unexpected or sudden event. Utility outages are considered emergencies. Emergency Response Plan: Section (page 10) emergency includes staged or total evacuation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 7 residents (Resident#122) reviewed for unnecessary drugs. The facility failed to ensure the stop date and diagnosis and/or indication for use was appropriate prior to administering Rocephin, an antibiotic. This failure could place residents receiving medications at risk of a possible adverse drug reaction or hospitalization. Findings included: Record review of Resident #122's face sheet (undated) revealed a [AGE] year-old female admitted to facility on 02/10/2023. Her diagnoses included hepatic encephalopathy (a nervous system disorder brought on by severe liver disease). Record review of Resident #122's admission MDS dated [DATE] did not mention the BIMS score. Record review of Resident #122's baseline care plan dated 02/10/2023 revealed: Problem: Impaired skin integrity; Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown; Implementation: Assess for adverse effects of medications. Resident was not care planned for receiving antibiotics. Record review of Resident #122's physician orders dated 02/11/2023 revealed an order for Ceftriaxone (Rocephin) 1 gram daily at 9:00am. Record review of Resident #122's MAR dated February 2023 revealed resident received Ceftriaxone (Rocephin) 1 gram daily at 9:00am. There was no diagnosis or stop date listed for the medication. Observation of the Med pass on 02/12/2023 at 9:46 a.m., revealed LVN A administered Resident #122's Ceftriaxone (Rocephin) 1 gram administered over 3-5 minutes IV push. In an interview on 02/12/2023 at 11:53 a.m., the LVN A said, I think Resident #122 is on Rocephin for suspected UTI because she had altered mental status when admitted to the hospital. In an interview on 02/13/2023 at 9:30 a.m., this Surveyor reviewed Resident #122's physician order with the DON. The DON said the order for the ABT was missing the diagnosis and the stop date. She said she did not know why the resident was receiving the ABT. In a later interview on 02/13/2023 at 9:50 a.m., she said she texted Resident #122's doctor and he said the ABT was for hepatic encephalopathy. She said the doctor said he would come and add the stop date today. She said the system was when a resident was admitted to the facility the admission orders go to the physician electronically. The physician then noted agreement/changes/discontinued orders. Then the orders were sent to the pharmacy electronically. The pharmacy printed the medications on the MAR and medications were sent to the floor. They should always put a diagnosis for medications. This should have been caught by the pharmacy or the nurse. They would be responsible for ensuring the medications are correct. She said there was no direct policy or protocol for receiving orders for medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two (Resident #72 and Resident #120) of seven residents reviewed for storage of medications. The facility failed to ensure: -Resident #72's medication was kept in a secure location. Resident #72 had physician's ordered Nystatin (antifungal medication used in skin treatments) powder at the bedside. -Resident #120 medication was kept in a secure location. Resident # 120 had no physician's order for Timolol Maleate Solution 0.5 % eye drops sitting on top of the bedside table. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Resident #72 Record review of Resident #72's clinical record revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included necrotizing fasciitis (a bacterial infection that destroys tissue under the skin) of left abdomen. Record review of Resident #72's baseline care plan dated 02/06/2023 revealed: Problem: Impaired skin integrity; Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown; Implementation: Assess for adverse effects of medications; Continued review of the care plan did not reveal Resident #72 could keep the Nystatin powder at the bedside. Record review of Resident #72's physician's order dated 02/07/2023 revealed Nystatin powder 100,000 units per Gram. Apply to groin daily. Continued review of the physician's orders did not reveal an order to keep at the bedside. Observation on 02/12/23 at 9:00 AM in room [ROOM NUMBER] B revealed Resident #72 in bed. Resident was not interviewable. A bottle of Nystatin powder 100,000 units per Gram was on a table in the resident room. In an interview on 02/12/2023 at 9:11 AM, LVN A stated Resident #72 did not have a physician's order to keep her Nystatin powder at the bedside. LVN A stated the medication was to be kept in the medication room or on the medication cart. LVN A stated Nystatin powder required a physician's order to administer. LVN A stated it was the responsibility of the nurse to make sure there were no medications at the bedside. LVN A continued and stated the risk of the medication at the bedside was that a visitor or someone who should not have it could take it. Resident #120 Record review of the admission sheet (undated) for Resident #120 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fall wedge fracture of 1st lumber. Record review of Resident #120's admission MDS dated [DATE] did not mention the BIMS score. Record review of Resident #120's Baseline care plan, dated 01/31/2023 revealed the following care plan: Problem: Impaired skin integrity Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown Implementation: Assess for adverse effects of medications. Resident #120 was not care planned for having meds at bedside. Observation and interview on 02/12/2023 at 8:42a.m., of Resident #120, in her room, revealed a bottle of Timolol Maleate Solution 0.5 % eye drops sitting on top of the bedside table. Resident #120 said her family member brought the eye drops and she administered herself day and night for glaucoma. Record review of Resident #120's physician's order revealed she was not prescribed the above-mentioned medication of Timolol Maleate Solution 0.5 % eye drops. There were no orders for self-administration. Observation and interview on 02/12/2023 at 8:55 a.m., with LVN A, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. LVN A said home meds had to be sent to the pharmacy to verify. Home meds were kept in the med room in their cubie. She said, I have taken care of Resident #120 multiple times. I don't know how the eye drops got in her room. LVN A said the resident did not have orders for it. In an and record review on 02/12/2023 at 1:15 p.m. This Surveyor reviewed Resident #120's physician orders with LVN A. LVN A said the resident did not have an order for eye drops. In an interview on 02/13/23 at 9:50 a.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said she was not aware of Resident #120 having meds at bedside. Record review of the facility's policy, Medication Management Storage, review dated 03/23/2022, read in part Policy: Medications, biologicals, and devices shall be stored to ensure their integrity, stability, and effectiveness. All drugs and biologicals will be controlled, secured, and distributed in accordance with applicable standards of practice and consistent with Federal and State laws and regulations . Medications may be stored only in authorized locations .All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals . Record review of facilities Home Medications policy (revision/Review Date: 7/2020) revealed read in part: .Procedure: For patients who will bring medications from home to the Skilled Nursing Unit: 1. Their medications must be contained in a bag or container that seals tight. 2. Home Medications must have the appropriate label from the pharmacy. 2. All home medications will be sent to our pharmacy to be verified.6. Patients' home medication must be kept locked up at all times; except when dispensing them. This is a State requirement and can also be a HIPAA violation .