Health inspection·March 9, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 12 residents reviewed for advanced directives. (Resident #37) The facility failed to ensure Resident #37's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #37's face sheet dated [DATE] revealed Resident #37 was [AGE] years old male, admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of gastrointestinal hemorrhage (stomach, intestinal bleeding), Dysphagia (difficulty swallowing), cerebral infarction (stroke) and dementia. Record review of a MDS dated [DATE] indicated Resident #37 was able to understand and was understood by others. The MDS indicated Resident #37 had memory problems and his BIMS score was 0 indicating severe cognitive impairment. The assessment indicated Resident #37 required limited assistance with bed mobility, extensive assistance with dressing, toilet use and personal hygiene and was independent with transfers, walking, and eating. Record review of a care plan dated [DATE] with an update of the care plan on [DATE] indicated Resident #37 had requested a code status of full code. The goal was his wishes regarding his code status will be maintained on an ongoing basis by the staff being informed of his code status, and to make changes to his code status at his request. Record review of consolidated physician orders dated [DATE] revealed an order for Full Code status on [DATE]. Record review of a handwritten physician order dated [DATE] revealed a DNR (Do Not Resuscitate) status. Record review of Resident #37's OOH-DNR (out of hospital do not resuscitate) form dated [DATE] revealed Resident #37's daughter, two witnesses, and his physician signed indicating there would be no resuscitation measures initiated or continued for Resident #37. Page 1 of 16 455569 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #37's electronic medical record on [DATE] revealed heart-shaped symbol and CPR (cardiopulmonary resuscitation) in red letters. These symbols indicated to provide CPR. During an interview on [DATE] at 1:06 p.m., LVN A indicated Resident #37's electronic record indicated he was designated a full code status. LVN A indicated Resident #37's paper chart had a signed OOH-DNR (out of hospital do not resuscitate), a physician's order for DNR, and a red colored paper indicating a DNR status. LVN A indicated the discrepancy could cause Resident #37 to receive resuscitation efforts against his and his family's wishes. During an interview on [DATE] at 1:18 p.m., the DON indicated Resident #37 could receive resuscitation efforts due to the full code status indicator on the electronic record. During an interview on [DATE] at 3:24 p.m., the Administrator indicated Resident #37 could have received CPR (cardiopulmonary resuscitation) against his wishes. The administrator indicated the social worker was responsible for updating the resident's code status on admission or with changes. The administrator indicated the care planning process should as well be a time the code status was reviewed for accuracy. The administrator said ultimately, she was responsible for ensuring the code status of the residents were honored. During an interview on [DATE] at 3:30 p.m., the DON indicated the social worker was responsible for ensuring audits were conducted on the code status of each resident. The DON indicated the SW was out ill at this time. Record Review of a policy dated [DATE] named, Do Not Resuscitate Order revealed the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 6. The Interdisciplinary Care Planning Team will review advance directives with the residents during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 455569 Page 2 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 12 residents reviewed for quality of care. (Resident #45) Residents Affected - Few The facility did not thoroughly conduct a comprehensive weekly skin assessment for Resident #45. This failure could place residents at risk for decreased quality of care and injury. Findings included: Record review of a face sheet dated 05/8/20 indicated Resident #45 was [AGE] years old, re-admitted on [DATE] with diagnosis including Quadriplegia (paralysis of all four limbs), anxiety (Intense, excessive, and persistent worry and fear about everyday situations), Peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), and Heart failure (condition in which the force of the blood against the artery walls is too high). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #45 made himself understood and understands others. Resident #45 had a BIMS (brief interview for mental status) score of 7 which indicated Resident #45 was moderately cognitively impaired. The assessment indicated Resident #45 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #45 required total dependence with bed mobility, dressing, toileting, eating, personal hygiene and bathing. The MDS indicated that Resident #45 at risk of developing pressure ulcers and injury. Record review of the care plan revised on 08/12/21 indicated Resident #45 had the potential for self-care deficit in ADLs related to Quadriplegia (paralysis of all four limbs). Interventions: provide total assistance for mobility, dressing, eating, toileting, personal hygiene, oral care, and bathing. The care plan indicated that Resident #45 had diagnosis of Diabetes Mellitus and was at risk for frequent infections, pressure, venous and statis ulcers, and physical limitations. Interventions: Monitor and document skin weekly and report to physician for changes, redness, circulatory problems and breakdown. During an observation on 03/09/22 at 08:41 a.m., CNA D provided incontinence care for Resident #45. A dressing was on his upper left buttock dated 02/16/22. LVN A, entered room and verified a dressing was intact to resident #45 's upper left buttock which had BHP initials and dated 02/16/22. LVN A, removed dressing that had dark brown drainage to inside of dressing and observed three open area to upper left buttock. During an observation and interview on 03/09/22 at 09:18 a.m., the DON and the treatment nurse (TX) entered the room and they both confirmed that Resident #45 had three open areas to upper left buttock. During an interview on 03/9/22 at 9:30 a.m., The wound care physician said she assessed areas to Resident #45's upper left buttock. She said the wounds were trauma/adhesive dressing superficial wounds and she was going to recommend moisture barrier with no more tape. The wound care physician said 455569 Page 3 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident # 45 had a history of skin issues and that he had a recent healed area to upper left buttock. The wound care physician said she had given a verbal order to apply a dry dressing to upper left buttock area until dressing dislodgement a few weeks ago. The wound care physician said she expected the dressing to stay intact to skin for about one to two weeks depending on the resident. During an interview on 03/09/22 at 09:48 a.m., LVN A said she was not aware of anything on resident #45's buttock. She said the nurses were responsible for the skin assessments and that they had an assignment list at the nurses' station. LVN A looked at the assignment sheet and said Resident #45 skin assessment was due on the night shift of 03/8/22. During an interview on 03/09/22 at 09:58 a.m., CNA E said she was unaware of any skin issue on Resident #45 until 03/9/22. During an interview on 03/09/22 at 10:01 a.m., Resident #45, said staff told him the area was healed to his buttock area, but that they were putting dressings on for prevention. Resident #45 said that the dressing has been on there a while, but when he asked, staff said the area looked good. Resident #45 said he had his bed bath on Monday, but he did not ask about his skin. During an interview on 03/09/22 at 10:38 a.m., CNA D said she did not see any dressing on Resident #45 when she provided care on 03/7/22. She saw dressing on 03/9/22, when providing bowel incontinence care. CNA D also verified that dressing on Resident #45 upper left buttock was dated 02/16/22 with initial BHP on dressing. During an interview on 03/09/22 at 01:48 p.m., the treatment nurse (TX) said she was not aware of resident #45 having had any skin issues to his buttock area. She said the last time she remembered; he had an area to lower back that had resolved. TX nurse said she did not remember that the wound care doctor had given a verbal order to apply a dry dressing until dislodgement. She said that staff had received an order today from Resident #45 primary physician to apply barrier cream to left side of lower back. TX nurse said it is the charge nurse's responsibility to make sure assessments are done; they have an assigned schedule that they are to follow. If any resident had a wound stage two or greater, then she was responsible for weekly assessments. TX nurse said failure to assess skin could harm skin integrity, wound healing and could cause infection to the wound. During an interview on 03/09/22 at 03:02 p.m., CNA F, said she gave resident #45 a bed bath on 03/7/22. She said he had a dressing on his back but unsure of date on dressing. During an interview on 03/09/22 at 03:05 p.m., LVN G, said she was not aware of any open areas to resident #45. She saw resident #45's torso (central part, or the core, of the body) area on 03/7/22, but did not see any open area or dressing to that area. During an interview on 03/09/22 at 03:21 p.m., LVN B, said she did a complete skin assessment on resident #45 on her shift of 03/8/22 but did not see any open areas on his skin nor any kind of dressing on his skin. During an interview on 03/09/22 at 02:09 p.m., the DON said nurses were responsible for the assessments, but TX nurse should follow up. TX nurse was responsible to do treatments daily and nurses in her absent. DON said that if treatments and assessment were not done as assigned; it could cause wounds to worsen or one to developed and staff not aware. 455569 Page 4 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/09/22 at 02:42 p.m., ADM said wounds are to be done by the TX nurse and doctor. ADM expected dressing to be in place as needed to any wounds and for the residents to receive the right amount of nutrition to help with wound healing. She said management nurses should follow up. Record review did not identify any prior order written for staff to apply dressing to upper left buttock area. Residents Affected - Few Record review of shower sheet reviewed for 03/7/22 did not indicate any skin issues on resident #45. Record review of skin assessment completed on 03/9/22 revealed no skin issues on resident #45. Record review of Braden risk assessment (Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores) dated 03/9/22 for resident #45 had a risk score of 13. Which indicated a moderate risk for skin breakdown. Record review of policy revised July 2017, The purpose of this procedure is to provide information regarding identification of pressure ulcers/injury risk factors and interventions for specific risk factors. Risk Assessment shall be performed on admission and weekly and upon any changes in condition. implemented interventions o Implemented care plan and monitored 455569 Page 5 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide appropriate treatment and service of care for 1 of 3 residents reviewed with a clinically justified indwelling catheter.(Resident #10) The facility failed to ensure resident # 10's indwelling catheter securement device was in place. This failure could place residents at risk for urethral tears, discomfort, infection and hospitalization. Findings included: Record review of a face sheet dated 11/10/15 indicated Resident #10 was [AGE] years old, re-admitted on [DATE] with diagnosis including Bacteremia (bacteria in the circulating blood), Alzheimer's and Hemiplegia (paralysis of muscles on one side of the body). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #10 usually made himself understood and understood others. Resident #10 had a BIMS (brief interview for mental status) score of 9 which indicated Resident #10 was moderately cognitively impaired. The assessment indicated Resident #10 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #10 required total dependence with transfers, dressing, toileting; extensive assist with bed mobility, personal hygiene and bathing; supervision with eating. The MDS for Resident #10 indicated that he has an indwelling catheter. Record review of the care plan revised on 02/24/22 indicated Resident #10 had the potential for self-care deficit in ADLs related to Alzheimer's and left BKA (below the knee amputation). Interventions: assist with mobility, dressing, eating, toileting, personal hygiene, oral care, and bathing. Also, resident #10 has a foley catheter with diagnosis of neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Interventions: apply leg strap to thigh. During an observation on 03/07/22 at 09:41a.m., resident # 10 was lying in his bed with without an indwelling catheter securement device in place. During an observation on 03/08/22 at 09:57 a.m., CNA C, providing care resident #10 without an indwelling catheter securement device (leg strap) in place. During an observation on 03/09/22 at 08:32 a.m., CNA D in room providing care, resident noted without an indwelling catheter securement device in place. During an observation on 03/09/22 at 01:13 p.m., the DON applied an indwelling catheter securement device to resident #10. During an interview on 03/09/22 at 10:42 a.m., CNA D said that resident #10 should have an indwelling catheter securement device on to keep it from pulling out. During an interview on 03/09/22 at 10:48 a.m., resident #10, said he wanted a cloth strap on his 455569 Page 6 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0690 leg because the tape irritated his leg. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/09/22 at 01:36 p.m., CNA E said a foley catheter leg strap is needed to keep the foley catheter from pulling out and for safety. Residents Affected - Few During an interview on 03/09/22 at 01:44 p.m., LVN A said resident # 10 did not have a foley catheter leg strap on until DON went to apply it earlier. LVN A said the importance of having on a leg strap was to help the flow of urine and prevent pulling of catheter. During an interview on 03/09/22 at 01:44 p.m., the DON said the importance of having a catheter foley strap in place was to prevent dislodging of foley and prevent infection. During an interview on 03/09/22 at 02:42 p.m., the ADM said she expected for the residents to have on a catheter foley leg strap to prevent the foley from pulling out when turning the resident. Record Review of policy revised September 2014 stated, Ensure that catheter remain secure with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Catheter stabilization shall be used to preserve the integrity and position of the catheter. 455569 Page 7 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

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 respiratory care was provided consistent with professional standards of practice for 3 of 12 residents reviewed for respiratory care. (Resident #20, Resident #35 and Resident #247). Residents Affected - Some The facility failed to date the oxygen tubing for Resident #35 and Resident # 247. The facility failed to properly store the oxygen tubing for Resident 35. The facility did not ensure Resident #20 nebulizer (a device used to deliver liquid medication in an aerosol form to a resident's lungs) was dated and stored properly when not in use. These failures could place residents who required respiratory care at risk for respiratory infections. Findings included: 1. Record review of the face sheet dated 07/1/20 indicated Resident #35 was [AGE] years old, readmitted on [DATE] with diagnoses of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Heart Failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), and Parkinson (disease of the nervous system). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #35 made himself understood and understood others. Resident #45 had a BIMS (brief interview for mental status) score of 15 which indicated he was cognitively intact. The MDS indicated Resident #35 required extensive assist with bed mobility, dressing, toileting, personal hygiene and bathing; set up help for eating. The MDS indicated that Resident #35 required oxygen. Record review of the care plan dated 01/20/22 for Resident #35 indicated he was at risk for SOB (shortness of breath), chest pain and increased edema. Intervention: Apply oxygen as ordered. Record review of the Physician order dated 11/15/21 indicated Resident #35 was to have oxygen at 3 liter per nasal cannula while in bed and as needed when out of bed. During an observation on 03/07/22 at 10:19 a.m., water canister dated 03/4/22 but no date on tubing and tubing was on the floor. During an observation on 03/8/22 at 09:06 a.m., Resident #35 in his bed with HOB (head of bed) up, alert and watching TV. Noted oxygen tubing with no date and tubing on floor, not properly stored. During and observation on 03/09/22 at 10:08 a.m., resident #35 in his bed, oxygen tubing on concentrator but not properly stored. 2. Record review of the face sheet dated 04/7/20 indicated Resident #20 was [AGE] years old, readmitted on [DATE] with diagnoses of COVID (a highly contagious respiratory disease), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing) and Diabetes 455569 Page 8 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0695 Mellitus. Level of Harm - Minimal harm or potential for actual harm Record review of the care plan for Resident #20 had no indication for nebulizer treatments. Residents Affected - Some Record review of the Physician order dated 03/2/22 indicated Resident #20 was to have Albuterol Sul 2.5MG/3ML Solution, give 1 inhalation every six hours as needed for SOB (shortness of breath) or wheezing. During an observation on 03/07/22 at 09:35 a.m., HHN (handheld nebulizer) machine on nightstand with no date on tubing and not stored properly. During and observation on 03/08/22 at 11:25 a.m., Resident # 20 in her bed with HHN machine on nightstand with no date on tubing and not stored properly. During an observation on 03/09/22 at 01:32 p.m., Resident #20 in her bed alert, HHN machine on nightstand with no date on tubing and not stored properly. 3. Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident is a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems. Observation on 03/07/22 09:35 AM revealed that Resident #247 had oxygen on at 3L/min no dates on oxygen tubing. Observation on 03/09/22 01:50 PM revealed that Resident #247 had returned to his room after therapy and did not have date on oxygen tubing. During an interview on 03/09/22 at 02:05 p.m., LVN A said that HHN tubing should be dated and, in a bag, when not in use. She said that her order was for PRN and she was not using at this time. DON removed HHN machine. LVN A said failure to properly store tubing could lead to infection. During an interview on 03/09/22 at 02:11 p.m., the DON said that her expectations was for tubing on oxygen and HHN should be changed every Sunday night and should have nurse initial and date on tubing and water canister. She said if tubing was not being used, tubing should be properly stored and failure to properly change or store tubing could cause infection. During an interview on 03/09/22 at 02:42 p.m., the ADM said she was not sure when oxygen and HHN tubing should be changed but felt like the DON was responsible to make sure this is happening. Failure to make sure that oxygen and HHN tubing are changed could lead to residents becoming sick and can lead to an infection control issue. During an interview on 03/09/22 at 03:35 p.m., LVN H said water canisters and tubing for oxygen and HHN should be changed out every Sunday nights; nurse should initial and date when changed. If tubing was not in use it should be properly stored. Failure could cause the resident an infection. 455569 Page 9 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0695 Level of Harm - Minimal harm or potential for actual harm Record review of policy revised October 2010; steps 29-30 indicate: When equipment is completely dry, store in plastic bag with residents' name and date on it and change equipment and tubing every seven days. Residents Affected - Some 455569 Page 10 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen days for 1 of 12 residents selected for unnecessary medications review. (Resident #18) Resident #18 had a PRN order for Zolpidem (Ambien), a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary medications. Findings include: Record Review of face sheet indicated Resident #18 admitted [DATE], was [AGE] years old with diagnoses that included: acute respiratory failure with hypoxia, endocarditis, (inflammation of the heart), Chronic obstructive pulmonary disease (respiratory symptoms with airflow limitation), congestive heart failure (weakened heart muscle causing fatigue and edema), anxiety disorder (nervousness, trembling, increased heart rate), and chronic pain. Record review of Resident #18's physician's orders dated March 2022 indicated: 1/27/22 Zolpidem Tartrate 5 mg tablet, one tablet at bedtime as needed. Record review of the MDS dated [DATE] indicated Resident #18 had clear speech, understood others, and was understood by others. The MDS indicated she was cognitively intact. The MDS indicated she had not had any hypnotic (medications used to induce, extend, or improve sleep) medications in the last 7 days. Record review of the care plan dated 1/3/22 indicated Resident #18 was at risk for side effects related to psychotropic medication therapy. The care plan indicated she had difficulty getting to or staying asleep related to insomnia. Record review of the Narcotic Administration Record dated 2/7/22 (indicated receipt of Zolpidem Tartrate, 5 mg tablet, one tablet at bedtime as needed.), through 3/8/22 indicated Resident #18 received the medication every day in February 2022 except 2/26/22. The Narcotic Administration Record indicated Resident #18 had received the medication 3/1/22 through 3/8/22. During an interview on 3/09/22 at 10:51 AM, the DON said the medication Zolpidem for Resident #18 was ordered 1/27/22 and was not received by the facility until 2/7/22. During an interview on 3/09/22 at 12:40 PM, the DON said the order for Zolpidem for Resident #18 did not have an end date. She said it should have had an end date of 14 days. She said the order for Zolpidem was written by the physician on 1/27/22, but the medication was not delivered to the facility until 2/7/22. 455569 Page 11 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/09/22 at 1:06 PM, the DON said they do not have an unnecessary medication policy. She said she talked with corporate and confirmed there was no unnecessary medication policy. She said the risk of continuing an antipsychotic past 14 days could be addiction. During an interview on 3/09/22 at 1:20 PM, the ADON said Resident #18's Zolpidem should have had an end date of 14 days. She said the risk of not having an end date could be oversedation (sleepiness, fatigue) of the resident. During a record review on 3/09/22 at 3:06 PM, Resident #18 had no documented side effects of Zolpidem medication. (This information was accessible by the facility computer only and could not be printed.) During a record review 3/9/33 at 3:11 PM of the Behaviors Roster, Resident #18 had no documented behaviors 1/1/22 through 3/9/22. During an interview on 3/09/22 at 3:24 PM, the administrator said she expected any antipsychotics ordered for residents to have a stop date within 14 days. She said they did not have a policy regarding unnecessary medications. An Antipsychotic Medication Use policy dated December 2016, provided by the DON 3/9/33 at 3:52 PM indicated: .14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication . 455569 Page 12 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 12 residents reviewed in sample (Resident # 247). The facility failed to have resident medications stored and locked in an area not accessible to other staff, residents, or visitors. This failure could place residents at risk of injury by eating or drinking medications. Findings included: Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident was a 73year old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems. Record review of Resident #247 Physician Orders dated March 2022 revealed that Resident #247 had an order dated 03/09/2022 for medication Diclofenac 1% gel to apply to joints and back QID (four times a day) PRN (as needed) for pain. Observation on 03/07/22 at 09:35 AM revealed that Resident #247 was in his room and had medication Diclofenac 1% cream was on his bedside dresser. Observation on 03/08/22 at 09:54 AM revealed that Resident was in bed resting. Said he did not sleep well night before. diclofenac 1% gel was on his bedside dresser. Observation on 03/09/22 at 08:34 AM revealed that Resident was in bed finishing up breakfast. Diclofenac 1% gel and pain cream was on his bedside dresser. Interview on 03/09/2022 at 01:50 PM with Resident #247 revealed that resident said he had medications brought to him, by his nephew, three days after he admitted (03/28/2022). He said he used it three times a day on his knees and back. Resident #247 said he did not know he could not keep medication in his room. Interview on 03/09/2022 at 02:11 PM with LVN H revealed that LVN H was unaware that Resident #247 had medications in his room. LVN H removed medications. LVN H said she would call doctor and get order for medication found in room and call the family to notify. LVN H said she knew that residents could not keep any medication in the room, and it must be locked in cart for nurse to administer. LVN H was not aware of a policy that residents can administer their own medications on a nursing facility. 455569 Page 13 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/09/2022 at 02:16 PM with DON revealed that DON said residents should not have medications in their rooms. All medications should be in the med room or carts locked. DON said families bring things into the facility that we are not aware of. What about that? She then walked off. Interview on 03/09/2022 at 02:20 PM with Administrator revealed that administrator said she was not aware of any resident self-medicating, so medications should not be in resident rooms. Medications should be in carts. She said she expected all nurses to check medications they bring in when residents admit and ensure orders are in place. Administrator said all medications should be given by the nurse. This could be a hazard to all residents. Policy for Storage of Medications dated April 2007, stated .The facility shall store all drugs and biologicals in a safe, secure, orderly manner. 455569 Page 14 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that, - Two stand up freezers that held frozen meat and vegetables had a large accumulation of food particles and crumbs on the bottom of both freezers. -Four bottles of buttermilk with use by dates of 2/21/22 were in the milk refrigerator. These failures could affect all residents who receive meals from the kitchen and place them at risk for foodborne illness. Findings Included: During an initial kitchen observation on 3/7/22 at 10:01 a.m., 2 of 2 stand up freezers that held frozen meat and vegetables had large accumulations of food particles, crumbs, and a yellow sticky substance on the bottom of both freezers. The refrigerator that held the milk had 4 bottles of buttermilk with use by dates of 2/21/22. During an interview on 3/7/22 at 10:10 a.m., the DM said that the freezers had scheduled cleaning days and that she thought that they were due to be cleaned. The DM said that she expected all kitchen equipment to be kept clean and that failure to do so could cause contamination of the food. She said that dietary aides were responsible for cleaning the freezer but ultimately it is her responsibility to ensure they were being cleaned. The DM said that the expired milk should have been removed or separated from the good milk so that it could have been sent back to the milk company. The DM said that she thought that the milk company checked dates on the milk when they delivered but that it was her responsibility to ensure expired milk was removed from the refrigerator. The DM said failure to remove expired foods could result in illness to the residents. A dietary services cleaning schedule indicated freezers were to be deep cleaned every 2 weeks on the morning shift. The freezers were due to be cleaned on 3/5/22 but were not signed out as cleaned. During an interview on 3/10/22 at 1:15 p.m., the DM said she did not have a policy related to expired food. During an interview on 3/10/22 at 3:00 p.m., the administrator said she expected kitchen equipment to be kept clean and expired foods to be disposed. She said it was the DMs responsibility to ensure these things were being completed but that it was also her responsibility to follow up. The administrator said failure to keep kitchen equipment clean and not removing expired food could have a negative outcome for the residents. Review of the facility policy Refrigerators, Coolers and Freezers, dated 2018, indicated . The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed. 455569 Page 15 of 16 455569 03/09/2022 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The U.S. Food and Drug Administration Food Code dated 2017 reflected: .3-305.11 Food Storage. (B) .refrigerated, ready- to -eat/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: In a clean, dry location. 455569 Page 16 of 16