**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #13) of 9 residents reviewed for advanced directives in that: Resident #13 had a DNR in her record with no physician information. This failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Record review of Resident #13's face sheet printed 5-13-2024 revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (a group of thinking and social symptoms that interferes with daily functioning), aortic valve deficiency (condition in which the heart's aortic valve does not work properly), cardiac arrythmias (improper beating of the heart, whether irregular, too fast, or too slow), and atherosclerosis (a buildup of fat, cholesterol, and other substances in the artery walls). Section Advance Directives listed Resident #13 as a DNR (Do Not Resuscitate). Record review of Resident #13's last MDS was a quarterly assessment completed 2-7-2024 listing her with a BIMS score of 8 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up to touch assistance with activities of daily living. Record review of Resident #13's care plan with admission date of 10-27-2022 revealed the following: Focus: Resident has a DNR on chart. Date initiated 11-11-2022. Goal: Resident and family wishes will be honored for the next 90 days and ongoing. Date initiated 11-11-2022. Target date 5-12-2024 Interventions: If resident is found no breathing, do not do CPR . Date initiated 11-11-2022. Revision on 2-12-2024. Record review of the clinical record for Resident #13 revealed an Order Summary with active orders as of 5-1-2024 with the following order: DNR (with an order date of 10-27-2022) Record review of the clinical record for Resident #13 revealed a DNR dated 10-24-2022 (signed by Declaration of the adult person) with the following: Section: Physician's Statement-there is no physician signature, no date for the physician's signature, no printed signature, and no license number. Section: All persons who have signed above must sign below, acknowledging that this document has been completed-there is no attending physician signature. During an interview on 05-13-2024 at 02:50 PM RN A and LVN B both reported all residents in the facility were currently DNR's except for one resident which was not Resident #13 so Resident #13 was currently a DNR. RN A reported that Resident #13 was a DNR which meant that if Resident #13 was to be found not breathing or without a heartbeat they would not perform resuscitative measures and keep her comfortable. LVN C agreed with RN A. Both reported that they would notify the residents family member and the physician. RN A then checked Resident #13's DNR and was unable to find the physicians information. Then RN A asked LVN C to check Resident #13's DNR form. LVN C was also unable to find any physician information on Resident #13's DNR form. RN A and LVN C reported that due to the physician not signing the DNR form for Resident #13 the DNR was invalid and since the resident was currently stable, they would get the form corrected immediately and hope that Resident #13 did not have a decline in her condition but if Resident #13 did have a change in her condition Resident #13 would be considered a full code. During an interview on 05-14-2024 at 12:56 PM AC C reported that the DNR part of resident care was not her department, that nursing takes care of the DNR process. AC C reported that the DNR was not her responsibility. During an interview on 05-15-2024 at 08:51 AM the DON reported that when a resident code's all staff were to verify the code status on the front of the residents MAR and then handle the situation properly. The DON reported that AC C was to verify all paperwork to include the DNR when a resident was admitted and that she (the DON) verifies the DNR's accuracy. The DON reported that with Resident #13's DNR form, it had so many signatures with both witnesses and the notary that the physician section was just missed, it fell through the cracks. The DON reported that the social worker verifies the DNR with each care plan meeting each quarter and that the social worker recently resigned, and their new social worker has not had time to learn the new process. The DON reported that if a DNR was not correctly completed it would be invalid and it would mean the resident would need to be resuscitated (have CPR started) and would be revived. The DON reported that there would be a potential for the resident to be harmed. Record review of the facility provided policy titled Advanced Directives Policy and Procedures undated, revealed the following: It is the policy of the facility to include elements and component that have an impact on the resident's health care in accordance with state law. .the facility will comply with the requirement of state law governing Advance Directives. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure stored food was properly labelled and dated. The facility failed to discard leftover food by use by date on the label. These failures could place residents at risk of food borne illness. Findings included: An observation on 05/13/24 at 09:30 AM of shelving in the kitchen revealed the following: A plastic lidded tub of what appeared to be heart-shaped cereal with no label and no date. A plastic lidded container of whipped vanilla frosting with an open date of 05/03/24. The lid was ballooning up as if pressure was inside the container. The manufacturer's instructions read to cover and refrigerate for up to 30 days after opening. A resealable plastic bag containing 12-15 bread-like objects in roundish asymmetrical shapes approximately 2-3 inches in diameter with no label or date. An observation on 05/13/24 at 09:33 AM of the walk-in refrigerator revealed the following: An open bottle of yellow electrolyte drink ¾ full with no open date. A pitcher approximately 1/10th full of cloudy, yellowish liquid labelled pineapple juice and dated 05/07/24. 3 whole heads of lettuce no date. 1 partial head of what appeared to be lettuce wrapped in plastic wrap no date. 1 partial head of lettuce in original packaging open to air with brown slimy substance on packaging and a cut edge of lettuce. Cardboard box of tomatoes with no date. One tomato of several visible in the box had a brownish caved in area the size of a $.50 piece. Round plastic lidded container labelled as whole tomatoes half full of red liquid open to air as the lid was warped and not sealed. Round plastic lidded container labelled as cherry pie filling with the following dates 04/22/24 and 04/28/24. Non-dairy whipped topped in original plastic bag packaging, half full. The end of the bag was not secured, open to air. Cheese slices with the following dates 04/22/24 and 04/28/24. An observation on 05/13/24 at 09:48 AM of freezers revealed the following: Box of pork sausage with no date. Box of tilapia with no date. 6 pies with no date 1 bag of round cream-colored objects approximately 2 inches in diameter with no label or date. Box of individual ice cream cups no date. Bag of round white disks approximately ½ inch thick and 3-4 inches across with no label or date. Box of pizza with no date. Box of waffles with no date. Box of meat with no date. During an interview on 05/14/24 at 09:34 AM ADM stated they do not have any kitchen policies regarding food labelling, storage, and leftovers. During an interview on 05/14/24 at 12:36 PM DM stated she did not have food policies. She said she followed the Texas Food Establishment Rules regarding food storage. She stated she had verbal trainings with her staff almost every day but did not have any written copies of the trainings or sign in sheets for trainings. DM stated she had trouble with her staff remembering to label and date food appropriately. She stated leftover food was to be thrown away in 3 days to keep residents from getting sick. DM stated she has trained her staff to label food and date it the day it was made and the day it needed to be thrown out. She stated food in the freezers should be labelled with the date received on the case and on any individual packages taken out of the case. During an interview on 05/15/24 at 08:44 AM DM stated residents could get sick if food was stored without correct labels, dates, refrigeration or if food is not thrown out when scheduled. She said, They (residents) can get sick if we serve it to them and don't know when we put it in there (refrigerator). During an interview on 05/15/24 at 08:46 AM DS stated leftover food was to be labelled and dated with the day it was made and three days after. She stated the food should be thrown out 3 days after it was made. She stated residents could get sick if food was not labelled and dated correctly. DS stated she had been trained to label food with the date cooked and the date it needed to be taken out of the freezer or refrigerator. She stated she was trained to date cases of food on the day they were received from the truck. Record review of facility policy titled Foods Brought by Family/Visitors and dated December 2008 revealed the following: . 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Record review of facility policy titled Refrigerators and Freezers and dated December 2008 revealed the following: . 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Record review of the undated pages of the Texas Food Establishment Rules provided by DM revealed the following: . A date marking system . may include: . 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 . or discarded . Food packaged in a food establishment, shall be labeled . Label information shall include: (A) the common name of the food, or absent a common name, an adequately descriptive identity statement; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to: A. Ensure stored food were properly labeled and dated. B. Ensure that frozen foods were properly labeled and dated C. Ensure that expired foods were not in the pantry, refrigerator, and freezer. These failures could place residents who ate the food at risk for food-borne illness. Findings include: Observation of the refrigerator on 3/15/23 at 10:00AM revealed the following: 1. Thousand Island dressing opened 9/14/2022 with expiration date 11/3/22. 2. 1 gallon of vanilla extract with expiration date 6/22/2022. 3. 1 gallon of BBQ Sauce with expiration date 1/21/2023. 4. 1 open 8oz Boost nutritional drink which was not dated. 5. ½ bell pepper in a clear plastic bag which was not dated. 6. 1 2-pound bag of carrots which was not dated. 7. 1 clear bag of cilantro which was not dated. 8. 2 large bags of celery which were not dated. 9. 1 open 12oz. bottle of orange Gatorade, ½ full, which was not dated. Observation of the walk-in pantry on 3/15/2023 at 10:30am revealed the following: 1. 1 Food Service box curly lasagna noodles, which was open to the air and not dated. 2. 1 Food Service bag of Navy Beans opened 2/21/23 with a best by date of 2/1/23. 3. 2 12oz. bottles Balsamic vinaigrette with best by date of 12/28/22. 4. 1 Food Service bottle [NAME] food coloring with expiration date of 7/11/2010. 5. 1 Food Service bottle light corn syrup, open and sitting on pantry shelf, with label which states, Refrigerate After Opening. 6. 1 open Food Service bottle Worchester Sauce, not dated. 7. 1 Food Service bottle red wine vinegar with expiration date of 7/1/22 and open date of 8/27/22. 8. 1 Food Service container unsweetened baking cocoa opened 8/25/22 with expiration date of 3/11/22. Observation of the freezer on 3/15/23 at 2:00PM revealed the following: 1. One large food service bag of hushpuppies, open to air, not dated. 2. One large food service bag of bread sticks, open to air, not dated. 3. One large food service bag of frozen spinach, open, not dated. 4. One food service bag of frozen cheddar cheese shreds, open, not dated 5. One food service bag of frozen hashbrowns, open, not dated 6. On food service bag of Mozzarella cheese shreds with expiration date of 12/6/22 7. One food service box of crinkle cut French Fries with expiration date of 9/1/22 In an interview on 3/15/2023 at 2:30PM, the Dietary Manager states that all kitchen staff are responsible for keeping the pantry area clean. Staff are trained in making sure expired food is thrown away and in keeping the pantry clean. Dietary manager states the negative outcome of having expired food in pantry is that it can attract bugs or ants. DM states that they do not have a policy and procedure book but follow the Texas Food Establishment Rules dated March 15, 2006. In an interview on 3/16/2023 at 9:00 am, the Administrator states that they do not have a policy and procedure book but uses the Texas Food Establishment book that the DM has in her office. Administrator states that in the last six months of QAPI meetings they have not discussed any kitchen issues and that no residents have gotten sick due to expired foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 of 16 residents (Resident #71) whose records were reviewed. Resident #71 had been admitted longer than 14 days and no comprehensive (MDS) assessment had been completed for him. This failure could lead to the facility being unable to identify residents' preferences, needs and functional abilities, which could place them at risk of receiving inappropriate care or not receiving necessary care for their condition(s). Findings Include: Record review of Resident #71's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of the assessments section of Resident #71's chart revealed that there were no MDS assessments on file or completed for the resident. During an interview on 01/27/2022 at 9:39 AM, DON reported that she was responsible for completing MDS assessments and that an admission MDS should be completed for every resident within 14 days of their admission date. DON reported that no MDS assessment had been completed for Resident #71 yet even though he was admitted over 14 days ago because I'm not able to do all the things that I need to do and that there's too much stuff to do. DON reported that MDS assessments are completed to identify conditions that might require intervention, and that not completing them on time could cause them to miss something. Record review of facility provided policy titled Resident Assessment Instrument, dated April 2010, revealed in part: Policy Statement A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Policy Interpretation and Implementation 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 1 medication room reviewed. The facility failed to ensure that an insulin pen was labeled with an open or expiration date when it was opened. This failure could place residents at risk of exposure to medications and/or biologicals that are expired and/or contaminated. Findings include: During an observation and interview on [DATE] at 11:00 AM, there was an insulin pen of insulin glargine (Lantus) 100 units per 1 milliliter in the facility medication room that was open and had 80 units of the medication missing from the container (220 units of the total 300 units remained). The insulin pen was not labeled or dated to indicate when it had been opened or put into use. RN A was present during the observation and reported that the insulin pen did not contain a date to indicate when it had been opened. RN A reported that the insulin pen was currently in use for a resident. RN A reported that it should have been dated with the open date when it was opened by the nurse who initially opened it because the insulin pen expires 28 days after being opened, and the date is needed to know when the 28 days will be reached. RN A reported that the consequences of not labeling insulin with an open date include that no one would know how long ago it was opened so they wouldn't know when it expires or if it was already expired. RN A reported that she did not know why the insulin pen was not labeled with an open date. During an interview on [DATE] at 9:50 AM, DON reported that it is our policy to date all of our insulin (with an open date) to ensure we are getting rid of them in the appropriate time, which is 28 days. DON reported that the potential consequences of not labeling insulins with an open date include that it (insulin) could grow some bacteria or lose effectiveness. DON reported that she did not know why there was an insulin pen in the facility medication room that was open and not labeled with an open date. Record review of facility provided policy titled Labeling of Medication Containers, dated [DATE], revealed in part: Policy Interpretation and Implementation 3. Labels for individual drug containers shall include all necessary information, such as: h. The expiration date when applicable; Record review of facility provided policy titled Insulin Administration, dated [DATE], revealed in part: Steps in the Procedure 4. Check the expiration date if drawing from an opened multidose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months (92 days) for 13 of 16 residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, and Resident #19) whose records were reviewed. The facility failed to complete an assessment (MDS) for residents Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, Resident #8, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, and Resident #19 at least once every 3 months (92 days). This failure could lead to the facility being unable to identify residents' preferences, needs and functional abilities, which could place them at risk of receiving inappropriate care or not receiving necessary care for their condition(s). Findings Include: Record review conducted on 01/27/2022 of Resident #2's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #2's most recently completed MDS assessment, dated 10/13/2021, revealed that the assessment was completed on 10/13/2021, 107 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #3's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #3's most recently completed MDS assessment, dated 09/15/2021, revealed that the assessment was completed on 09/15/2021, 135 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #4's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #4's most recently completed MDS assessment, dated 09/15/2021, revealed that the assessment was completed on 09/15/2021, 135 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #6's face sheet, dated 12/01/2021, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #6's most recently completed MDS assessment, dated 10/13/2021, revealed that the assessment was completed on 10/13/2021, 107 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #7's face sheet, dated 12/01/2021, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #7's most recently completed MDS assessment, dated 09/15/2021, revealed that the assessment was completed on 09/15/2021, 135 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #8's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #8's most recently completed MDS assessment, dated 10/26/2021, revealed that the assessment was completed on 10/26/2021, 94 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #10's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #10's most recently completed MDS assessment, dated 10/13/2021, revealed that the assessment was completed on 10/13/2021, 107 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #12's face sheet, dated 12/01/2021, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #12's most recently completed MDS assessment, dated 09/22/2021, revealed that the assessment was completed on 09/22/2021, 128 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #13's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #13's most recently completed MDS assessment, dated 08/18/2021/2021, revealed that the assessment was completed on 08/18/2021, 163 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #14's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #14's most recently completed MDS assessment, dated 10/20/2021, revealed that the assessment was completed on 10/20/2021, 100 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #15's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #15's most recently completed MDS assessment, dated 10/20/2021, revealed that the assessment was completed on 10/20/2021, 100 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #17's face sheet, dated 01/03/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #17's most recently completed MDS assessment, dated 10/20/2021, revealed that the assessment was completed on 10/20/2021, 100 days prior to the day of the record review. Record review conducted on 01/27/2022 of Resident #19's face sheet, dated 01/03/2022, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #19's most recently completed MDS assessment, dated 09/08/2021, revealed that the assessment was completed on 09/08/2021, 142 days prior to the day of the record review. During an interview on 01/27/2022 at 9:39 AM, DON reported that she was responsible for resident MDS assessments and that an MDS assessment should be completed on every resident at least every 12 weeks, or 92 days. DON reported that all facility resident MDS assessments were currently past due except for 5 of them because I'm not able to do all the things that I need to do and that there's too much stuff to do. DON reported that MDS assessments are completed to identify conditions that might require intervention, including possible changes in condition, and that not completing them on time could cause them to miss something. Record review of facility provided policy titled Resident Assessment Instrument, dated April 2010, revealed in part: Policy Interpretation and Implementation 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. at least quarterly;