Health inspection·November 15, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 22 (Residents #61) residents reviewed change of condition. The facility did not ensure Physician D was notified when Resident #61 was exhibiting suicidal ideation on 11/12/23. This failure could place residents at risk of a delay in treatment or interventions, worsening of their physical and psychological condition, and a decreased quality of life. The findings included: Record review of the face sheet, dated 11/15/23, revealed Resident #61 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of retention of urine, acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), gross hematuria (presence of red blood cells in the urine), and BPH (condition in which the flow of urine is blocked due to the enlargement of prostate gland). Record review of the comprehensive MDS assessment, dated 10/27/23, revealed Resident #61 had clear speech and was understood by staff. The MDS revealed Resident #61 was able to understand others. The MDS revealed Resident #61 had a BIMS of 11, which indicated moderately impaired cognition. The MDS revealed Resident #61 had a PHQ-2 of 0, which indicated no depressive symptoms. The MDS revealed Resident #61 had no behaviors or refusal of care. The MDS revealed Resident #61 had an indwelling catheter. Record review of the comprehensive care plan, revised on 11/13/23, revealed Resident #61 had an order for PRN anxiety medication due to increased anxiety with current foley catheter placement or pain. The interventions included: monitor, record, and report to the physician side effects and adverse reactions of psychoactive medications .suicidal ideations .behavioral symptoms not usual to the person . Record review of the nursing progress note, dated 11/12/23, revealed Resident #61 voiced not wanting to be alive to the medication aide then RN N went to his room to perform an assessment. RN N documented Resident #61 stated he did not want to be in the nursing home. He wants to be home with his dog. Resident #61 stated if he had a 38, he would use it. Nurse asked the patient if he wanted to Page 1 of 43 455579 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few committee suicide. Resident #61 stated he would not do it, but he doesn't want to be in the nursing home. He wants to be home with his dog. Nurse administered PRN anxiety medication to Resident #61 and then contacted family. Nurse asked if family could possibly bring dog up to cheer Resident #61 up, family stated they could not but would speak to him. Family spoke with Resident #61, and he began to calm down. Physician D notified of possible need for psych consult. DON notified of suicidal ideation; DON stated to place order to monitor behaviors. Order placed to monitor behaviors. During an interview on 11/15/23 beginning at 8:10 AM, RN N stated a medication aide, whose name she did not remember, reported to her that Resident #61 was making comments that indicated he did not want to be alive. RN N stated Resident #61 told her I wished I had a 38, I would just end it. RN N said she asked Resident #61 if he wanted to take his life and he told her No, I won't do it, but I don't want to be at the nursing home and I miss my dog. RN N said she called Resident #61's family and they spoke with him, which seemed to calm him down. RN N stated she notified the DON, and she told her to add behavior monitoring every shift. RN N stated she continued to check on Resident #61, administered an antianxiety medication, and placed cream on his groin area to help with the pain. RN N stated Resident #61 had no further episodes and made no further comments about wanting to die. RN N stated Physician D did not want to be bothered on the weekend, so she wrote the incident down in his book, but did not call him. During an interview on 11/15/23 beginning at 8:12 PM, the DON stated she was notified on 11/12/23 that Resident #61 was having suicidal ideation. The DON stated she requested RN N to add an order to monitor behaviors, notify the physician to ask for a psych evaluation, and then check on Resident #61 frequently, at least every few hours. The DON stated RN N told her Resident #61 did not have a plan to commit suicide but did not want to be in the nursing facility. The DON stated because it was the weekend, the nurses would have put the incident in Physician D's book to review when he was at the facility. The DON stated it was documented that Physician D was notified of possible need for psych consult, but she was unsure if it was ordered. The DON stated there was no order for a psych consult and a psych consult had not been made. The DON stated she expected the nursing staff to notify the physician immediately if a resident expressed suicidal ideations so interventions could have been implemented immediately. During an interview on 11/15/23 beginning at 8:39 AM, Physician D stated he was not notified of Resident #61's suicidal ideations during the weekend. Physician D stated he would have remembered that phone call. Physician D stated he expected the facility to immediately notify him of any residents who express suicidal ideation. Physician D stated he would have instructed the facility staff to send Resident #61 to the emergency room for a psych evaluation. Physician D stated the facility staff were able to contact him on the weekend and often received calls and texts during the weekend. Physician D stated it was important to notify him of suicidal ideations so appropriate actions and interventions could have been implemented so residents did not act upon the suicidal thoughts. During an interview on 11/15/23 beginning at 9:02 AM, Resident #61 stated he did not want to die, he just wanted to get over this crap and quit being a burden. Resident #61 stated he was recently admitted to the facility where he has been dependent on staff. Resident #61 stated he missed his home and his dog. Resident #61 stated a few days prior to admitting to the facility he had a foley catheter inserted and it was causing him pain. Resident #61 stated he was supposed to have been getting a different catheter and has received pain medications and flushes. Resident #61 stated he wished the catheter could have been removed. During an interview on 11/15/23 beginning at 6:36 PM, the Administrator stated he expected staff to 455579 Page 2 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notify the physician for changes in a resident's condition. The Administrator stated the charge nurse was responsible for making the notifications and nursing management should have been monitoring it. The Administrator stated it was important to ensure the physician was notified for change in a resident's condition so the change could have been addressed. Record review of the Notification of Changes policy, revised 01/10/20, revealed the facility will immediately inform the . resident's physician . of the following: 3. A significant change in the physical, mental, or psychosocial status of the resident. 455579 Page 3 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete Quarterly MDS assessment was transmitted to the CMS System within 14 days after completion for 1 of 22 residents (Resident #54) reviewed for MDS assessments. Residents Affected - Few The facility did not ensure Resident #54's Quarterly MDS assessment, dated 09/27/2023, and completed on 09/28/2023, was transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of a face sheet dated 11/15/2023, indicated Resident #54 was a [AGE] year-old male, admitted to the facility on [DATE], with a primary diagnosis of Parkinsonism (a clinical syndrome characterized by tremors, slowed movements, postural instability, and stiffness). Record review of Resident #54's Quarterly MDS assessment dated [DATE] indicated it was completed on 09/28/2023 (Section Z0500B). Record review of Resident #54's electronic health record on 11/15/2023, indicated the Quarterly MDS assessment was completed but had not been transmitted and accepted to the CMS system. During an interview on 11/15/2023 at 3:29 PM, the MDS Coordinator said Resident #54's Quarterly MDS assessment dated [DATE] was not transmitted. The MDS Coordinator said she was not sure why Resident #54's Quarterly MDS assessment was not transmitted. The MDS Coordinator said an RN outside of the building was signing the MDS assessments completed and transmitting them. The MDS Coordinator said the Quarterly MDS assessment should be transmitted 14 days after it was signed complete. The MDS Coordinator said it was important for the MDS assessments to be transmitted timely due to the state regulations. During an interview on 11/15/2023 at 3:49 PM, the facility's Regional Reimbursement Consultant said the MDS Coordinator was responsible for transmitting the MDS assessments. The Regional Reimbursement Consultant said Resident #54's Quarterly MDS assessment dated [DATE] was not transmitted. The Regional Reimbursement Consultant said Resident #54's MDS assessment was not transmitted because there must have been a glitch with the system. The Regional Reimbursement Consultant said once a month she looked through the completed MDS assessments to ensure they were completed correctly and transmitted. The Regional Reimbursement Consultant said she had not had a chance to review the ones from last month to ensure they were transmitted. The Regional Reimbursement Consultant said the Quarterly MDS assessment should be transmitted 14 days after it was completed. The Regional Reimbursement Consultant said it was important for the MDS assessments to be transmitted timely because it could affect the quality measures. During an interview on 11/15/2023 at 5:21 PM the Administrator said the MDS Coordinator transmitted the MDS assessments, and the Regional Consultant reviewed the MDS assessments. The Administrator said he expected the MDS assessments to be transmitted timely. The Administrator said it was important 455579 Page 4 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0640 Level of Harm - Minimal harm or potential for actual harm for the MDS assessments to be transmitted timely to give an accurate picture of the resident at the time the MDS assessment was completed. Record review of the facility's policy titled, MDS Accuracy Guidelines, revised, 10/24/2022, did not address transmitting the MDS assessments. Residents Affected - Few Record review of the CMS RAI (Resident Assessment Instrument user manual) Version 3.0 Manual: Chapter 2, page 2-17, dated October 2019, indicated, Quarterly (Non-Comprehensive) transmission date 455579 Page 5 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 2 of 22 residents (Residents #20 and #59) reviewed for care plans. 1. The facility did not develop Resident #20's care plan related to him being PASRR positive effective 04/01/2023. 2. The facility did not develop Resident #59's care plan related to Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation) effective 10/06/2023. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings included: 1. Record review of Resident #20's face sheet, dated 11/15/2023, indicated Resident #20 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (serious mental illness characterized by extreme mood swings, major depressive disorder, and generalized anxiety disorder. Record review of Resident #20's annual MDS assessment, dated 05/17/2023, indicated Resident #20 understood others and made himself understood. The assessment indicated Resident #20 had a BIMS score of 12, which indicated his cognition was moderately impaired. The assessment indicated in Section A1500 Resident #20 was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of Resident #20's care plan, initiated on 11/15/2023, indicated the facility IDT had determined that Resident #20 deemed PASRR positive on the PASRR evaluation. The care plan interventions included, appointed facility staff to schedule IDT meetings as required so that all necessary team members are in attendance and IDT meeting will be conducted with the designated LIDDA/LMHA representative annually and as needed for significant change in status. The care plan did not address Resident #20's PASRR status prior to surveyor entrance to the facility on [DATE]. 2. Record review of Resident #59's face sheet, dated 11/15/2023, indicated Resident #59 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included chronic viral Hepatitis C. Record review of Resident #59's admission MDS assessment, dated 10/18/2023, indicated Resident #59 usually understood others and usually made herself understood. The assessment indicated Resident #59 had a BIMS score of 3, which indicated her cognition was severely impaired. The assessment indicated Resident #59 had a diagnosis of a viral hepatitis. Record review of Resident #59's care plan, revised on 11/13/2023, did not address Resident #59 diagnosis of Hepatitis C. During an interview and record review on 11/15/2023 beginning at 1:36 p.m., the MDS Coordinator 455579 Page 6 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she was responsible for ensuring the care plan reflected that Resident #20 was PASRR positive. After reviewing Resident #20 care plan, the MDS Coordinator stated positive PASRR status should have been documented on the care plan. The MDS Coordinator stated he was a new positive PASRR for the facility and she overlooked his PASRR care plan. The MDS Coordinator stated she monitored and oversees care plans by random audits. The MDS Coordinator stated the last audit was completed in August by herself and the former DON. The MDS Coordinator stated Resident #20 care plan was one of the ones that was audited but was unsure how it was missed. The MDS Coordinator stated Hepatitis C was not something that normally would be care plan. The MDS Coordinator stated the only time it would be triggered would be under dehydration. The MDS Coordinator stated if the patient was able to independently take fluids, Hepatitis C would not be something that should be care plan. The MDS Coordinator stated it was important to ensure the care plan reflected that Resident #20 was PASRR positive to monitor for any changes or services he may need. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he expected PASRR and Hepatitis C to be care plan. The Administrator stated the DON and himself oversees and monitoring the MDS Coordinator by reviewing the care plan quarterly. The Administrator stated the last review was done the third of October. The Administrator stated Resident #20 and #59 care plans was not reviewed at that time. The Administrator stated it was important to ensure the care plan reflected Resident #20 was PASRR positive and Resident #59 had a diagnosis of Hepatis C to make sure the facility had plans in place to deal with those issues. Record review of the facility's policy titled Comprehensive Care Plans implemented 02/10/2021, indicated, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment 3. The comprehensive care plan will describe, at a minimum, the following: c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations 455579 Page 7 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received services to maintain personal hygiene for 2 of 64 (Residents #10 and #21) residents reviewed for ADLs. Residents Affected - Few 1. The facility failed to ensure Resident #10's fingernails were trimmed routinely. 2. The facility did not ensure Resident #21's fingernails were trimmed and free from a brown colored substance routinely. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: 1. Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and obstructive sleep apnea (intermittent airflow blockage during sleep). Record review of the quarterly MDS assessment dated [DATE], indicated Resident #10 usually understood others and made himself understood. The assessment indicated Resident #10 had a BIMS score of 8, which indicated his cognition was moderately impaired. The assessment indicted Resident #10 did not have any behavioral symptoms or rejection of care with ADLs. The assessment indicated Resident #10 required extensive assistance with personal hygiene. Record review of Resident #10's care plan, revised on 06/23/2023, indicated Resident #10 had an ADL self-care performance deficit and was at risk for not having his needs met in a timely manner. The care plan interventions included, maximum assistance of 1 with personal hygiene, and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. During an observation and interview on 11/13/2023 at 9:34 a.m., Resident #10 was sitting in his recliner watching tv. Resident #10's fingernails on both hands were jagged and appeared to be approximately 0.25 cm long. Resident #10 stated he would like his nails to be trimmed but the facility was shorthanded. Resident #10 stated due to him being a diabetic his nails must be cut by a nurse. During an observation on 11/14/2023 at 8:53 a.m., Resident #10 was sitting in his recliner watching tv. Resident #10's fingernails on both hands were jagged and appeared to be approximately 0.25 cm long. 2. Record review of Resident #21's face sheet, dated 11/15/2023, indicated Resident #21 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis (chronic inflammatory disorder affecting many joints, including those in the hands and feet). Record review of the quarterly MDS assessment dated [DATE], indicated Resident #21 understood others and made herself understood. The assessment indicated Resident #21 had a BIMS score of 8, which 455579 Page 8 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated his cognition was moderately impaired. The assessment indicated Resident #21 did not have any behavioral symptoms or rejection of care. The assessment indicated Resident #21 was dependent with personal hygiene. Record review of Resident #21's care plan, initiated 08/10/2020, indicated Resident #21 had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan interventions included, maximum assistance x1 with personal hygiene and provide shower, shave, oral care, hair care, and nail care per schedule and when needed. During an observation and interview on 11/13/2023 at 10:18 a.m., Resident #21 was lying in bed watching tv. Resident #10 fingernails on both hands were jagged and appeared to be approximately 0.25-0.50 cm long with a thin line of brown substance under them. Resident #21 stated she would like her nails to be cut and cleaned. During an observation on 11/14/2023 at 8:55 a.m., Resident #21 was lying in bed watching tv. Resident #10 fingernails on both hands were jagged and appeared to be approximately 0.25-0.50 cm long with a thin line of brown substance under them. During an observation and interview on 11/15/2023 at 9:55 a.m., CNA Q stated she was responsible for nail care on Resident #21. CNA Q stated nurses were responsible for nail care on Resident #10. CNA Q observed with the surveyor Resident #21's nails and stated, they need to be cut and cleaned. CNA Q stated Resident #21 sometimes refused her bath or incontinent care but not nail care. CNA Q stated nail care should be done daily. CNA Q stated sometimes nail care such as trimming may not always get done because sometimes we're too busy. CNA Q stated she did trim Resident #21 nails the week of 11/08/2023. CNA Q stated it was important to ensure nail care was done to prevent bacteria from growing or an infection. During an observation and interview on 11/15/2023 at 12:55 p.m., RN L stated the nurse charges were responsible for cutting Resident #10 nails due to him being a diabetic. RN L observed with the surveyor Resident #10's nails and stated, his nails need to be cut. RN L stated she would have to find out how frequent the nails should be clipped. After clarifying with the DON, RN L stated the diabetic and non-diabetic resident's nails should be trimmed once a month. RN L stated CNAs were responsible for cutting the non-diabetic resident's nail. RN L stated it was important to ensure nail care was done to prevent an injury to the skin. During an interview on 11/15/2023 at 2:15 p.m., the DON stated she expected resident's nails to be clipped once a month depending on how long or jagged, they are. The DON stated she expected the CNAs to clean resident's nails daily and PRN. The DON stated she expected nurses to clip the diabetic resident's nails and the CNAs to do the non-diabetic. The DON stated this was monitored by daily quality of life rounds completed by the department heads. The DON stated it was important to ensure nail was done to prevent an infection. An attempted telephone interview on 11/15/2023 at 4:28 p.m. with ADON A, the one who was responsible for monitoring Resident #10 and #21 nail care, was unsuccessful. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he expected nails to be clean and clipped routinely and as needed. The Administrator stated it was important to ensure nail was done to a potential infection. 455579 Page 9 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0677 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Activities of Daily Living Care Guidelines reviewed 02/11/2021, indicated, residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Residents Affected - Few 455579 Page 10 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

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 residents requiring respiratory care were provided such care, consistent with professional standards of practices for 3 of 9 residents (Residents #10, #21 and #115) reviewed for respiratory care. Residents Affected - Some 1. The facility did not ensure Resident #10 and Resident #21's oxygen concentrator filters were cleaned. 2. The facility did not ensure Resident #21's oxygen was set at 3 LPM as ordered by the physician. 3. The facility did not ensure Resident #115's oxygen was set at 2 LPM as ordered by the physician. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings included: 1. Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and obstructive sleep apnea (intermittent airflow blockage during sleep). Record review of the order summary report dated 11/15/2023 indicated Resident #10 had an order for oxygen at 3 liters per minute via N/C every shift for prophylaxis with a start date 10/13/2022 and clean oxygen concentrator filter every night shift every Wednesday with a start date 10/18/2023. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #10 usually understood others and made himself understood. The assessment indicated Resident #10 had a BIMS score of 8, which indicated his cognition was moderately impaired. The assessment indicated Resident #10 did not have any behavioral symptoms or rejection of care. The assessment indicated Resident #10 was receiving oxygen therapy. Record review of Resident #10's care plan, revised on 06/23/2023, indicated Resident #10 used oxygen therapy routinely and at risk for ineffective gas exchange. The care plan interventions included, administer oxygen therapy per physician's orders, monitor for signs and symptoms of respiratory distress and report to the physician as needed. During an observation and interview on 11/13/2023 at 9:34 a.m., Resident #10 was sitting in his recliner watching tv wearing oxygen via nasal cannula. Resident #10's oxygen concentrator filter had a thick grey, fuzzy, material. Resident #10 stated he wore oxygen all the time due to him having shallow lungs. During an observation on 11/14/2023 at 8:53 a.m., Resident #10 was sitting in his recliner watching tv wearing oxygen via nasal cannula. Resident #10's oxygen concentrator filter had a thick grey, fuzzy, material. 2. Record review of Resident #21's face sheet, dated 11/15/2023, indicated Resident #21 was an 455579 Page 11 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included atherosclerosis of coronary artery (cholesterol and fat collects on the walls of blood vessels and forms plaque) bypass graft. Record review of the order summary report dated 11/15/2023 indicated Resident #21 had an order for oxygen at 3 liters per minute via N/C every shift for shortness of breath with a start date 10/17/2022 and clean concentrator filter weekly every night shift every Wednesday with a start date 10/18/2023. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #21 understood others and made herself understood. The assessment indicated Resident #21 had a BIMS score of 8, which indicated his cognition was moderately impaired. The assessment indicated Resident #21 did not have any behavioral symptoms or rejection of care. The assessment indicated Resident #21 was receiving oxygen therapy. Record review of Resident #21's care plan, initiated 08/10/2020, indicated Resident #21 used oxygen therapy routinely or as needed and at risk for ineffective gas exchange. The care plan interventions included, administer oxygen therapy per physician's orders, monitor for signs and symptoms of respiratory distress and report to the physician as needed. During an observation and interview on 11/13/2023 at 10:18 a.m., Resident #21 was lying in bed watching tv wearing oxygen via nasal cannula at 2.5 liters per minute. Resident #21's oxygen concentrator filter had a thick grey, fuzzy, material. Resident #21 stated she wore oxygen all the time due to shortness of breath. During an observation on 11/14/2023 at 8:55 a.m., Resident #21 was lying in bed watching tv wearing oxygen via nasal cannula at 2.5 liters per minute. Resident #21's oxygen concentrator filter had a thick grey, fuzzy, material. 3. Record review of Resident #115's face sheet, dated 11/15/2023, indicated Resident #115 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order summary report dated 11/15/2023 indicated Resident #115 had an order for oxygen at 2 liters per minute via N/C continuous every shift for COPD with a start date 11/07/2023. Record review of Resident #115's electronic medication record indicated Resident #115 was recently admitted and the comprehensive assessment was not yet required. Record review of Resident #115's baseline care plan, effective 11/07/2023, indicated Resident #115 used oxygen therapy routinely or as needed, and was at risk for infective gas exchange. The care plan interventions included, administer oxygen therapy per physician's orders, monitor for signs and symptoms of respiratory distress and report to the physician as needed. During an observation and interview on 11/13/2023 at 9:28 a.m., Resident #115 was lying in bed wearing oxygen via nasal cannula at 3 liters per minute. Resident #115 stated he wore oxygen due to COPD. During an observation on 11/14/2023 at 8:43 a.m., Resident #115 was lying in bed wearing oxygen via 455579 Page 12 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0695 nasal cannula at 2.5 liters per minute. Level of Harm - Minimal harm or potential for actual harm During an observation, interview, and record review on 11/15/2023 at 12:55 p.m., RN L observed with the surveyor Resident #10 and #21's oxygen concentrator filter and stated, it's dirty. RN L observed with the surveyor Resident #21's oxygen liters at 2.5 liters per minute and Resident #115's oxygen liter at 2.5 liters per minute. After reviewing Resident #21 and #115's electronic medical records, RN L stated the rate for Resident #21 should be 3 liters per minute and Resident #115 should be 2 liters per minute. RN L stated the charge nurses was responsible for ensuring oxygen settings were set at the correct LPM. RN L stated she would have to ask the DON who was responsible for ensuring the filters were clean. After clarifying with the DON, RN L stated the night nurses on Wednesdays were responsible for cleaning/changing the filters. RN L stated when she goes in the resident's room to assess the resident oxygen concentrator, she glanced to ensure it was at the correct liters. RN L stated after surveyor intervention the charge nurse should look at eye level to ensure the flowmeter ball was at the correct setting. RN L stated it was important the oxygen was set at the correct LPM and filters clean/change to ensure the resident get the proper oxygen to their organs. RN L stated these failures could potentially put residents at risk for pneumonia. Residents Affected - Some An attempted telephone interview on 11/15/2023 at 2:08 p.m. with LVN P, the LVN who was responsible for ensuring the filters were change/clean, was unavailable. During an interview on 11/15/2023 at 2:15 p.m., the DON stated she expected the nurses to ensure the oxygen concentrator settings match the physician orders. The DON stated she expected the oxygen concentrator filters to be either clean or change once a week by the 10p-6a nurse on Wednesday. The DON stated she monitored and oversees by randomly going into residents' room that required oxygen and look at the filter/settings. The DON stated this was done once a week. The DON stated she did not check west hall on last Friday where Residents #10, #21 and #115 resides. The DON stated the nurses should be checking the settings at eye level and looking to ensure the filters were cleaned prior to documentation on the MAR. The DON stated it was important to ensure oxygen was set at the correct LPM and filters clean/change to prevent increase carbon dioxide, desaturation, and respiratory infection. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he expected the oxygen concentrator settings to be accurate and filters cleaned. The Administrator stated it was important to ensure the physician orders were followed, oxygen was given at the prescribed rate and filters were clean/change to prevent a respiratory infection. Record review of the facility's policy titled Oxygen Administration reviewed 01/05/2020, indicated, to describe methods for delivering oxygen to improve tissue oxygenation Procedure (1) verify order . Concentrator (1) clean filter weekly . Record review of the oxygen concentrator user manual, dated 2020, revealed on page 14, 5.2 Clean and replace the filters as outlined in the paragraphs in order to protect the compressor The cabinet filter should be inspected periodically and cleaned as needed by the user or caregiver 455579 Page 13 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide mentally related social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 1 (Resident #61) residents reviewed for social services. Residents Affected - Few 1. The facility failed to ensure the Social Worker was notified and social services were provided after Resident #61 exhibited suicidal ideations on 11/12/23. 2. The facility failed to ensure Resident #61 received a psychiatric referral after he exhibited suicidal ideations on 11/12/23. These failures could place residents at risk for their mental and psychosocial needs not being met and a decreased quality of life. The findings included: Record review of the face sheet, dated 11/15/23, revealed Resident #61 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of retention of urine (holding urine in the bladder and inability to empty bladder fully), acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), gross hematuria (presence of red blood cells in the urine), and BPH (condition in which the flow of urine is blocked due to the enlargement of prostate gland). Record review of the comprehensive MDS assessment, dated 10/27/23, revealed Resident #61 had clear speech and was understood by staff. The MDS revealed Resident #61 was able to understand others. The MDS revealed Resident #61 had a BIMS of 11, which indicated moderately impaired cognition. The MDS revealed Resident #61 had a PHQ-2 of 0, which indicated no depressive symptoms. The MDS revealed Resident #61 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 11/13/23, revealed Resident #61 had an order for PRN anxiety medication due to increased anxiety with current foley catheter placement or pain. The interventions did not address social services needs. Record review of the order summary report, dated 11/14/23, revealed there was no order for a referral to psychiatric services. Record review of the nursing progress note, dated 11/12/23, revealed Resident #61 voiced not wanting to be alive to the medication aide then RN N went to his room to perform an assessment. RN N documented Resident #61 stated he did not want to be in the nursing home. He wants to be home with his dog. Resident #61 stated if he had a 38, he would use it. Nurse asked the patient if he wanted to committee suicide. Resident #61 stated he would not do it, but he doesn't want to be in the nursing home. He wants to be home with his dog. Nurse administered PRN anxiety medication to Resident #61 and then contacted family. Nurse asked if family could possibly bring dog up to cheer Resident #61 up, family stated they could not but would speak to him. Family spoke with Resident #61, and he began to calm down. Physician D notified of possible need for psych consult. DON notified of suicidal ideation; DON stated to place order to monitor behaviors. Order placed to monitor behaviors. 455579 Page 14 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0745 Level of Harm - Minimal harm or potential for actual harm Record review of the social services progress note, dated 11/15/23 at 9:04 AM, revealed the Social Worker was informed Resident #61 made a comment about wanting to die. The progress note stated the Social Worker and physician interviewed Resident #61 and he stated he did not want to kill himself and does not have an active plan. The progress note revealed Resident #61 had no intention for self-harm and his comments were age related and pain, which was being managed. Residents Affected - Few Record review of the social services progress note, dated 11/15/23 at 2:08 PM, revealed a psych referral was being signed and the psychiatrist agreed to see Resident #61 on 11/16/23. During an interview on 11/15/23 beginning at 8:10 AM, RN N stated a medication aide, whose name she did not remember, reported to her that Resident #61 was making comments that indicated he did not want to be alive. RN N stated Resident #61 told her I wished I had a 38, I would just end it. RN N said she asked Resident #61 if he wanted to take his life and he told her No, I won't do it, but I don't want to be at the nursing home and I miss my dog. RN N said she called Resident #61's family and they spoke with him, which seemed to calm him down. RN N stated she notified the DON, and she told her to add behavior monitoring every shift. RN N stated she continued to check on Resident #61, administered an antianxiety medication, and placed cream on his groin area to help with the pain. RN N stated Resident #61 had no further episodes and made no further comments about wanting to die. RN N stated she placed the incident on the 24-hour report sheet for continued monitoring and the need for a psychiatric referral. RN N stated she wrote the incident down in the Physician D's book, and did not notify him by telephone, so an order was not given for a psychiatric referral. During an interview on 11/15/23 beginning at 5:27 PM, the Social Worker stated she was responsible for ensuring psychiatric referrals were made. The Social Worker stated normally, nursing staff would have notified her immediate if a resident exhibited suicidal ideations. The Social Worker stated she should have been notified immediately when Resident #61 exhibited suicidal ideations. The Social Worker stated she could have initiated the psychiatric referral and could have walked the nursing staff through questioning that would have assessed his suicidal tendencies. The Social Worker stated it was important to implement social services for Resident #61 because she was educated and trained in psychosocial issues and could have implemented her social service education to ensure Resident #61's mental health was taken care of and ensured his safety. During an interview on 11/15/23 beginning at 8:12 PM, the DON stated she was notified on 11/12/23 that Resident #61 was having suicidal ideation. The DON stated she requested RN N to add an order to monitor behaviors, notify the physician to ask for a psych evaluation, and then check on Resident #61 frequently, at least every few hours. The DON stated RN N told her Resident #61 did not have a plan to commit suicide but did not want to be in the nursing facility. The DON stated because it was the weekend, the nurses would have put the incident in Physician D's book to review when he was at the facility. The DON stated it was documented that Physician D was notified of possible need for psych consult, but she was unsure if it was ordered. The DON stated there was no order for a psych consult and a psych consult had not been made. The DON stated social services should have been notified. The DON stated she believed a plan had been put in place with the Social Worker and nurse practitioner on 11/10/23 for Resident #61's manipulative behaviors. The DON stated she believed a psychiatric referral had already been made. The DON stated the Social Worker was responsible for making psychiatric referrals. The DON stated the DON or Administration was responsible for ensuring the Social Worker was notified if a resident had suicidal ideations. The DON stated it was important to ensure social services were received to maintain the residents mental and physical well-being. The DON stated it was important to ensure psychiatric referrals were made in a timely manner to ensure the resident's safety, and psychiatric services could have been implemented. 455579 Page 15 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0745 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 beginning at 6:36 PM, the Administrator stated he expected the Social Worker to be notified for resident's who exhibit suicidal ideations. The Administrator stated the charge nurse, then ADON, then DON were responsible for ensuring the Social Worker was notified. The Administrator stated it was important to ensure social services was notified so the facility staff could have been reactive toward interventions. Residents Affected - Few Record review of the Behavioral Health Services policy, implemented 11/20/22, revealed The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as .psychiatrists . 455579 Page 16 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 4 medication carts (North and [NAME] Hall) and 1 of 5 residents (Resident #20) reviewed for pharmacy services. 1. The facility did not ensure Resident #20's lactobacillus 0.2 mg (medication that is used to prevent or treat infections in children and adult) as ordered by the physician was administered instead of the lactobacillus 10 mg. 2. The facility did not ensure LVN M counted controlled drugs every shift change on 11/02/2023 and 11/05/2023. These failures could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: 1. Record review of Resident #20's face sheet, dated 11/15/2023, indicated Resident #20 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (bacteria). Record review of the order summary report, dated 11/15/2023, indicated Resident #20 had an order for lactobacillus 0.2 mg; 2 tablets by mouth three times a day for IBS (a disorder that affects the stomach and intestines) with a start date 03/01/2023. Record review of Resident #20's annual MDS assessment, dated 05/17/2023, indicated Resident #20 understood others and made himself understood. The assessment indicated Resident #20 had a BIMS score of 12, which indicated his cognition was moderately impaired. The assessment indicated Resident #20 was independent with eating, toileting; required supervision with dressing, personal hygiene; and extensive assistance with bathing. Record review of Resident #20's care plan, revised on 02/02/2023, indicated Resident #20 had impaired cognition and was at risk for further decline in cognitive and functional abilities related to dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). During an observation on 11/14/2023 at 8:14 a.m., MA B was preparing Resident #20's medication for administration. MA B obtained a bottle of lactobacillus 10 mg instead of 0.2 mg and placed two tablets in the cup. MA B gave Resident #20 her medication cup, which included the lactobacillus, and Resident #20 swallowed the medication. During an interview on 11/15/2023 at 12:55 p.m., RN L stated MA B should have matched the medication to the order prior to administering the medication. RN L stated when she noticed the medication bottle did not match the order, she should have not given the medication and notified the charge nurse. RN L stated it was important to ensure medications were administered per the physician order to 455579 Page 17 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0755 prevent an injury or death. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/152023 at 1:49 p.m., MA B stated she should have paid more attention by comparing the MAR to the physician order dose prior to administering the medication. MA B stated she knew that she was supposed to check the MAR to the medication with every medication pass but since he had been taking the medication for so long, she did not realize the dose was 0.2 mg instead of 10 mg. MA B stated it was important to ensure medications were administered per the physician order to prevent an overdose or an adverse reaction. Residents Affected - Few During an interview on 11/15/2023 at 2:15 p.m., the DON stated she expected the MAs or nurses to double check the order to the bottle prior to administration. The DON stated due to assuming the new position as a DON she did not have a system in place to monitor medication errors. The DON stated it was important to follow the physician order to prevent any adverse reaction to the wrong dose being given. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he expected the physician orders to be followed and dispense to what the order says. The Administrator stated it was important to follow the physician order to prevent any reactions to too much or too little. Record review of the facility's policy titled Medication-Treatment Administration and Documentation Guidelines revised 04/06/2023, indicated 1. verify labels accurately reflects the physician orders on the EMAR and ETAR prior to administering patient medications and treatments .2. verify administration accuracy by checking the medication with the EMAR three times 4. Administer the medication according to the physician order 2. During a record review and random count observation of [NAME] Hall medication cart with MA O on 11/15/2023 at 10:04 a.m. revealed missing signatures for On duty and Off duty for 11/02/2023 of the narcotic count sheet. During a record review and random count observation of North Hall medication cart with RN L on 11/15/2023 at 10:11 a.m. revealed missing signatures for On duty and Off duty for 11/05/2023 of the narcotic count sheet. During an interview on 11/15/2023 at 12:46 p.m., LVN M stated she should have signed the narcotic sheet before and after counting the narcotics on 11/2/2023 and 11/5/2023. LVN M stated she thought she had done it but, I forgot. LVN M stated it was important to count and sign the narcotic sheet before and after her shifts to ensure there was no discrepancies. During an interview on 11/15/2023 at 2:15 p.m., the DON stated she expected the MAs and nurses to sign the narcotic count sheet at the beginning and end of each shift. The DON stated the ADONs were responsible for ensuring the narcotic count sheets were completed by reviewing sheets weekly. The DON stated she relied on the ADONs to ensure certain duties are completed. The DON stated it was important to count and signed the narcotic sheets before and after their shifts to prevent a medication error and drug diversion. An attempted telephone interview on 11/15/2023 at 4:28 p.m. with ADON A, the one who was responsible for monitoring the narcotic sheets for North and [NAME] Hall, was unavailable. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he expected the nurses and 455579 Page 18 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MAs to sign the narcotic sheet at the beginning and end of their shift. The Administrator stated it was important to count and signed the narcotic sheets before and after their shifts to prevent a drug diversion. Record review of the facility's policy titled Drug Diversion Guidelines reviewed 02/10/2020, indicated, the following recommendations are designed to reduce and lit drug diversions: 5. A drug count must be done at each shift change and should be done whenever the keys to the narcotic storage areas are exchanged from one staff to another . 455579 Page 19 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #4) reviewed for (DRR) Drug Regimen Review. 1. The facility failed to timely implement Resident #4's signed Note to Attending Physician/Prescriber on 10/12/23, which agreed with the pharmacy recommendation to schedule Resident #4's antianxiety medication. 2. The facility failed to timely implement Resident #4's signed Note to Attending Physician/Prescriber on 10/12/23, which agreed with the pharmacy recommendation for a gradual dose reduction on an antidepressant medication. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Record review of the face sheet, dated 11/14/23, revealed Resident #4 was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses of major depressive disorder (disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (group of mental illnesses that cause constant fear and worry), and pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying). Record review of the quarterly MDS assessment, dated 08/14/23, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS of 3, which indicated severe cognitive impairment. The MDS revealed Resident #4 had a PHQ-9 of 15 which indicated moderately severe depression. The MDS revealed Resident #4 had verbal behavioral symptoms directed toward others 4 to 6 days during the 7-day look-back period. The MDS revealed Resident #4 had rejection of care daily. The MDS revealed Resident #4 had active psychiatric and mood disorder diagnoses. The MDS revealed Resident #4 received antianxiety and antidepressant medication 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, revised on 01/17/23, revealed Resident #4 used antianxiety and antidepressant medication. The interventions included: medication regime to be routinely reviewed by the pharmacist with all recommendations, including suggested reductions, to be forwarded on to the physician and evaluate effectiveness and side effects of medications routinely for possible decrease/elimination of psychotropic medications. Record review of the Note to Attending Physician/Prescriber, signed on 10/12/23, revealed Resident #4 had an order for buspirone (antianxiety) 5 mg every 8 hours PRN for anxiety. The recommendation note revealed the physician signed that he agreed with the pharmacy recommendation to schedule the buspirone. The order was not clarified or implemented until 11/14/23, which was 33 days after the signed order. Record review of the Note to Attending Physician/Prescriber, signed on 10/12/23, revealed Resident #4 had an order for sertraline (antidepressant) 100 mg every day. The recommendation note revealed 455579 Page 20 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the physician signed that he agreed with the pharmacy recommendation to decrease the sertraline to 75 mg every day. The order was not implemented until 11/15/23, which was 34 days after the signed order. Record review of the order summary report, dated 11/14/23, revealed Resident #4 had an order, which started on 09/19/23, for buspirone 5 mg - give 1 tablet by mouth every 8 hours as needed for anxiety. The order summary report revealed a new order, which started on 11/14/23, for buspirone 5 mg - give 1 tablet by mouth two times a day related to anxiety. The new order was implemented 33 days after the order was signed. The order summary report further revealed an order, which started on 12/20/22, for sertraline - give 100 mg by mouth in the morning for depression. The order summary report revealed a new order, which started on 11/14/23, for sertraline - give 75 mg by mouth in the morning for depression. The new order was implemented 34 days after the order was signed. Record review of Resident #4's MAR, dated November 2023, revealed buspirone 5 mg - give one tablet by mouth every 8 hours as needed was discontinued on 11/14/23 and a new order for buspirone 5 mg - give one tablet by mouth two times a day was scheduled to start on 11/14/23 at 4:00 PM. The MAR further revealed Resident #4 received sertraline 100 mg daily. The MAR revealed sertraline - give 100 mg by mouth in the morning was discontinued on 11/14/23 and a new order for sertraline - give 75 mg by mouth in the morning was scheduled to start on 11/15/23. Record review of the progress note, dated 11/14/23, revealed clarification was needed for Resident #4's pharmacy recommendation for the buspirone and clarification was given by the nurse practitioner. During an interview on 11/15/23 beginning at 4:57 PM, RN K stated she had been out of the facility for several months and returned on 11/10/23. RN K stated the charge nurse was responsible for ensuring pharmacy recommendations were placed in the computer. RN K was unsure why Resident #4's pharmacy recommendations were not placed in the computer on 10/12/23 as she was not working during that time. RN K stated it was important to ensure pharmacy recommendations were implemented to ensure residents received the correct medication dosages or prevent the residents from receiving unnecessary medication. During an interview on 11/15/23 beginning at 5:17 PM, ADON C stated the charge nurses were responsible for ensuring pharmacy recommendations were placed in the computer. ADON C stated the ADONs were responsible for monitoring and checking to ensure pharmacy recommendations were implemented. ADON C stated either she or the other ADON would have gotten the signed pharmacy recommendations from the DON and given them to the charge nurses. ADON C stated she would have gotten the pharmacy recommendations back from the nurses the next day and verified they were in the computer. ADON C stated she and the other ADON had been working the floor during the month of October and the DON would have been responsible for the pharmacy recommendations. ADON C stated it was important to ensure pharmacy recommendations were implemented timely to ensure unnecessary drugs were not given to the residents and to reduce the risk of adverse reactions. During an interview on 11/15/23 beginning at 5:42 PM, the DON stated she was responsible for ensuring pharmacy recommendations were completed. The DON stated pharmacy recommendations should have been implemented within 2-3 days after the physician has signed. The DON stated she started the position recently, during the month of October 2023. The DON stated the Regional Nurse Consultant helped her with the pharmacy recommendations in October as she had only been in the position for a few days. The DON stated she was still learning and the ADON's had been working the floor and she could have 455579 Page 21 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some overlooked the pharmacy recommendations. The DON stated it was important to ensure the pharmacy recommendations were implemented timely to ensure residents received the correct dosage and did not receive unnecessary medications. During an interview on 11/15/23 beginning at 6:36 PM, the Administrator stated he expected the nursing staff to ensure pharmacy recommendations were implemented timely. The Administrator stated the nursing management was responsible for monitoring to ensure pharmacy recommendations were implemented. The Administrator stated it was important to ensure pharmacy recommendations were implemented timely to ensure residents received the medications they needed at the lowest dose possible and to maintain their quality of care. Record review of the Drug Regimen Review Process, reviewed on 10/24/22, revealed the DON oversaw the pharmacy recommendations were completed timely up to 12 midnight the next night. The policy further revealed recommendations that require physician response are sent to physician timely for follow up .the don will maintain system to review and track all recommendations . to validate timely response .the DON will validate all recommendations .once returned are acted upon timely . 455579 Page 22 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs and the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications documented in the clinical record for 3 of 5 (Resident's #4, #10, and #36) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #4 received a gradual dose reduction of his anti-depressant medication. 2. The facility did not ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #10. 3. The facility did not ensure Resident #36's behaviors were adequately monitored regarding her antianxiety, and antidepressant medications. 4. The facility did not ensure Resident #36's adverse drug event was adequately monitored regarding her antianxiety, and antidepressant medications. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. The findings included: 1. Record review of the face sheet, dated 11/14/2023, revealed Resident #4 was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses of major depressive disorder (disorder that causes a persistent feeling of sadness and loss of interest) and pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying). Record review of the quarterly MDS assessment, dated 08/14/2023, revealed Resident #4 had clear speech and was understood by staff. The MDS revealed Resident #4 was able to understand others. The MDS revealed Resident #4 had a BIMS of 3, which indicated severe cognitive impairment. The MDS revealed Resident #4 had a PHQ-9 of 15 which indicated moderately severe depression. The MDS revealed Resident #4 had verbal behavioral symptoms directed toward others 4 to 6 days during the 7-day look-back period. The MDS revealed Resident #4 had rejection of care daily. The MDS revealed Resident #4 had active psychiatric and mood disorder diagnoses. The MDS revealed Resident #4 received an antidepressant medication 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, revised on 01/17/2023, revealed Resident #4 used an antidepressant medication. The interventions included: evaluate effectiveness and side effects of medications routinely for possible decrease/elimination of psychotropic medications. Record review of the Note to Attending Physician/Prescriber, signed on 10/12/2023, revealed Resident #4 had an order for sertraline (antidepressant) 100 mg every day. The recommendation note revealed 455579 Page 23 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the physician signed that he agreed with the pharmacy recommendation to decrease the sertraline to 75 mg every day. Record review of the order summary report, dated 11/14/2023, revealed Resident #4 had an order, which started on 12/20/2022, for sertraline - give 100 mg by mouth in the morning for depression. The order summary report revealed a new order, which started on 11/14/2023, for sertraline - give 75 mg by mouth in the morning for depression. The new order was implemented 34 days after the order was signed. Record review of Resident #4's MAR, dated November 2023, revealed Resident #4 received sertraline 100 mg daily. The MAR revealed sertraline - give 100 mg by mouth in the morning was discontinued on 11/14/2023 and a new order for sertraline - give 75 mg by mouth in the morning was scheduled to start on 11/15/2023. During an interview on 11/15/2023 beginning at 4:57 PM, RN K stated she had been out of the facility for several months and returned on 11/10/2023. RN K stated the charge nurse was responsible for ensuring pharmacy recommendations for GDRs were placed in the computer. RN K was unsure why Resident #4's GDR was not placed in the computer on 10/12/2023 as she was not working during that time. RN K stated it was important to ensure pharmacy recommendations for GDRs were implemented to prevent the residents from receiving unnecessary medication. During an interview on 11/15/2023 beginning at 5:42 PM, the DON stated she was responsible for ensuring pharmacy recommendations for GDRs were completed. The DON stated pharmacy recommendations for GDRs should have been implemented within 2-3 days after the physician has signed. The DON stated she started the position recently, during the month of October. The DON stated the Regional Nurse Consultant helped her with the pharmacy recommendations and GDRs in October as she had only been in the position for a few days. The DON stated she was still learning and the ADON's had been working the floor. The DON stated she could have overlooked the pharmacy recommendations for Resident #4's GDR of his antidepressant medication. The DON stated it was important to ensure the pharmacy recommendations for GDRs were implemented timely to ensure residents did not receive unnecessary medications. During an interview on 11/15/2023 beginning at 6:36 PM, the Administrator stated he expected the nursing staff to ensure pharmacy recommendations for GDRs were implemented timely. The Administrator stated the nursing management was responsible for monitoring to ensure pharmacy recommendations for GDRs were implemented. The Administrator stated it was important to ensure pharmacy recommendations for GDRs were implemented timely to ensure residents received the medications they needed at the lowest dose possible and to maintain their quality of care. 2. Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs). Record review of the order summary report, dated 11/15/2023, indicated an order that started on 10/14/2022 for Lamictal 100 mg; two tablets by mouth in the morning related to bipolar. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #10 usually understood others and made himself understood. The assessment indicated Resident #10 had a BIMS score 8, which indicated his cognition was moderately impaired. The assessment indicated Resident #10 did not have any behavioral symptoms or rejection of care. The assessment indicated Resident #10 had an active 455579 Page 24 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnosis of depression and bipolar disorder. The assessment indicated Resident #10 took an antipsychotic 7 out of 7 days during the look-back period. Record review of Resident #10's care plan, revised on 06/23/2023, indicated Resident #10 had the potential for mood problem related to bipolar disorder. The care plan interventions included, administer medications as ordered, and monitor/document for side effects and effectiveness. Record review of the MAR dated 11/01/2023-11/30/2023 indicated Resident #10 was receiving Lamictal 100 mg; two tablets by mouth in the morning related to bipolar disorder. Record review of the pharmacy recommendation, dated 10/12/2023, indicated Resident #10 was receiving Lamictal 100 mg: two tablets by mouth in the morning. The recommendation further indicated; could the resident tolerate a GDR or taper-off for Lamictal, the physician circled no. There was no indication or rationale provided for continued use. During an interview on 11/15/2023 at 2:48 p.m., the Regional Nurse Consultant stated the GDRs were done every three months. The Regional Nurse Consultant stated the DON was responsible for overseeing that the MD put a rationale for any GDR that did not agree the pharmacy recommendation. The Regional Nurse Consultant stated the DON should be reviewing the pharmacy recommendation binder monthly for any new GDR changes or disagreements to ensure there was a rationale for the disagreement with the MD and the pharmacy consultant. The Regional Nurse Consultant stated it was important to ensure clinical rationales were provided for continued use of psychotropic medications to ensure residents get the proper medication dose for their diagnosis. An attempted telephone interview on 11/15/2023 at 6:00 p.m. with Physician A, was unsuccessful. 3. Record review of Resident #36's face sheet, dated 11/15/2023, indicated Resident #36 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs) disorder, major depressive disorder, and unspecified psychosis (mental disorder characterized by a disconnection from reality). Record review of the physician order summary report indicated antipsychotic medication monitoring and target behavior for antianxiety medications was not implemented until 11/15/2023. Record review of Resident #36's admission MDS, dated [DATE], indicated Resident #36 understood others and made herself understood. The assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #9 received anxiety and antidepressant medications 7 out of 7 days during the look-back period. Record review of Resident #36's care plan, initiated on 11/07/2023, indicated Resident #36 used psychotropic medications related to bipolar disorder. The care plan interventions included, administer medications as ordered, and monitor/document for side effects and effectiveness. Record review of the MAR dated 11/01/2023-11/30/2023 indicated Resident #36 was receiving: *Sertraline 50 mg; 1 tablet by mouth in the morning for depression with a start date 10/20/2023. * Buspirone 15 mg; 1 tablet by mouth three times a day for bipolar disorder with a start date 455579 Page 25 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0758 10/19/2023. Level of Harm - Minimal harm or potential for actual harm * Gabapentin 600 mg; 1 tablet by mouth three times a day for anxiety with a start date 10/20/2023. * Hydroxyzine Pamoate 50 mg; 1 tablet by mouth every 8 hours as needed for anxiety. Residents Affected - Some During an interview on 11/15/2023 at 12:55 p.m., RN L stated when the charge nurses received an order for psychotropic medications a consent was obtained. RN L stated after the resident signed the consent, the order was sent to the pharmacy and then the nurse must watch the resident take the initial dose and then start the monitoring process. RN L stated when the nurse put the medication order in PCC, she should have checked the tab that stated, behavior side effect monitoring. RN L stated the behavior/side effect monitoring should be completed every shift. RN L stated it was important to monitor and document the behavior/side effect to ensure the medication was effective and to prevent increased anxiety and depression. During an interview on 11/15/2023 at 2:15 p.m., the DON stated the procedure for monitoring to ensure behaviors/side effects were monitored for residents on psychotropic medications was when the nurse received an order for the psychotropic medication, a consent was obtained. The DON stated the nurse must put the medication order in PCC, and checked the tab that stated, behavior side effect monitoring. The DON stated anyone that was on a psychotropic medication has to have an adverse monitoring order and a targeted behavior monitoring order. The DON stated it was important to monitor and document the behavior/side effect to ensure the medication was effective. During an interview on 11/15/2023 at 2:48 p.m., the Regional Nurse Consultant stated usually after a new admission or new psychotropic order the charge nurses put the orders in and the following day the ADON and DON would review the medication orders to ensure all adverse monitoring orders and targeted behavior monitoring orders were in place. The Regional Nurse Consultant stated due to the change of DON and the ADONs working the shifts that were not covered there had been a lack of reviewing and monitoring orders. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he was deferring to the DON regarding psychotropic medications documentation and GDRs because she was responsible for monitoring that system. Record review of the facility's policy titled; Antipsychotic Medication, reviewed 02/10/2020, indicated . it is the facility's policy that each resident's drug regimen is free from unnecessary drugs including unnecessary antipsychotic drugs For any resident who is receiving an anti-psychotic drug to treat a psychiatric disorder other than behavioral symptoms related to dementia, the GDR may be considered contraindicated if: a. continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder . 10. Antipsychotic drug for enduring conditions (i.e., non-acute, chronic, or prolonged), the target behavior/s will be clearly and specifically identified and documented in the clinical record in Progress Notes. 11. Antipsychotic medication side effects/adverse effects are monitored periodically by objective evaluation (at least quarterly) and ongoing. Report to the physician side effects and adverse effects for reevaluation of the antipsychotic medication 455579 Page 26 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 22 residents (Resident #10) reviewed for laboratory services. Residents Affected - Few The facility did not obtain a physician's ordered Hgb A1c (a blood test that measures the average blood sugar levels over the past three months) for Resident #10. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings included: Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included bipolar type 2 diabetes with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar and a type of nerve damage that can occur with diabetes) Record review of the order summary report, dated 11/15/2023, indicated an order for Hgb A1c every 3 months with a start date 03/02/2023. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #10 usually understood others and made himself understood. The assessment indicated Resident #10 had a BIMS score 8, which indicated his cognition was moderately impaired. The assessment indicated Resident #10 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of Resident #10's care plan, revised on 06/23/2023, indicated Resident #10 had a diagnosis of diabetes and was at risk for unstable blood sugars and abnormal lab results. The care plan interventions included, administer diabetic medications as ordered by the physician and monitor blood sugars as ordered by the physician. Record review of Resident #10's electronic medical record revealed Hgb A1c results obtained on 06/02/2023. There were no results found for the month of September 2023. During an interview on 11/15/2023 at 2:15 p.m., the DON stated she expected Resident #10 Hgb A1c to be checked every three months per physician orders. The DON stated the Hgb A1c should have been drawn on 09/01/2023. The DON stated after surveyor intervention she realized that the lab had not been obtained. The DON stated the previous DON would have been responsible for monitoring and overseeing to ensure the Resident #10 Hgb A1c was obtained per the physician order. The DON stated the risk associated with Resident #10 Hgb A1c not drawn could potentially cause elevated blood sugar and lead to complications such as nerve and kidney damage. During an interview on 11/15/2023 at 2:48 p.m., the Regional Nurse Consultant stated ADON A should have checked PCC (electronic medical records) monthly under results to ensure labs had been drawn per scheduled. The Regional Nurse Consultant stated due to the change of DON and the ADONs working shifts that were not covered there had been a lack of reviewing and monitoring lab orders. An attempted telephone interview on 11/15/2023 at 4:28 p.m. with ADON A, was unsuccessful. 455579 Page 27 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/15/2023 at 4:39 p.m., the Administer stated he expected the nurses to follow the physician orders. The Administer stated it was important to ensure labs were drawn per schedule to determine what level the A1c was at and to ensure the medication is appropriate. Record review of the facility's policy titled; Lab Tracking System, reviewed 02/12/2020, indicated . lab tracking tool are used by healthcare team to track and record timely completion of ordered lab tests . the center will use the routine lab tracking form to leg and track routine labs over the course of year Monthly a designated staff member will transcribe lab that is to be completed for that month from the routine lab tracking tool onto the corresponding lab tracking tool 455579 Page 28 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 22 residents (Resident's #4, #36, and #42) reviewed for palatable food. Residents Affected - Many The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #4, Resident #36, and Resident #42, who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 11/13/2023 beginning at 10:03 AM, Resident #36 stated the food was terrible. Resident #36 stated sometimes the food was cold. During an interview on 11/13/23 beginning at 11:24 AM, Resident #42 stated the food was tasteless and cold at times. During an interview on 11/13/23 beginning at 1:18 PM, Resident #4 was sitting up in his bed with the head of the bed elevated to an upright position. Resident #4 had his meal tray in front of him on his bedside table. Resident #4 stated the broccoli on his tray was okay but needed salt and pepper. Resident #4 stated the mashed potatoes were yuck, very bland. During an observation and interview on 11/14/23 beginning at 1:03 PM, a lunch tray was sampled by the RDO and three surveyors. The sample tray consisted of buttered diced carrots, which were bland. The RDO stated diced carrots were hot but agreed that they were bland and needed seasoning. During an interview on 11/15/23 beginning at 6:25 PM, [NAME] F stated received complaints sometimes about the food served cold and not having enough seasoning. [NAME] F stated she was responsible for ensuring the food was appropriate temperature and tasted good. [NAME] F stated it was important to ensure food was served at the appropriate temperature and tasted good, so the residents enjoyed eating it and the food did not make them sick. During an interview on 11/15/23 beginning at 6:28 PM, the DM stated he had not received any food complaints since working in the kitchen. The DM stated he expected food to have been served at the appropriate temperatures, looked good, and tasted good. The DM stated it was important to ensure the food was served at the correct temperature, looked good, and tasted good so the food did not make them sick and so they would not lose weight. During an interview on 11/15/23 beginning at 6:36 PM, the Administrator stated he had received several food complaints from different residents. The Administrator stated he expected dietary staff to ensure food was served at appropriate temperatures and was appetizing. The Administrator stated it was important to ensure food was served at correct temperatures, looked good, and tasted good so the residents would eat it and get the proper nutrition. Record review of the Food Safety and Sanitation Plan, revised on 10/24/22, revealed All foods kept 455579 Page 29 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0804 in a hot holding unit must be maintained at 135 F or above. The policy did not address food palatability or serving procedures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 455579 Page 30 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 2 of 2 meals (Lunch meal on 11/13/23 and 11/14/23) observed for frequency of meals. The facility did not serve the 11/13/23 and the 11/14/23 lunch meal at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings included: Record review of the facility's mealtimes indicated lunch was served at 12:00 PM. During an interview on 11/13/23 beginning at 11:20 AM, Resident #3's daily visitor stated she was concerned Resident #3 was served lunch at around 1:00 PM most of the time. Resident #3's visitor stated Resident #3 was supposed to be served her lunch around 12 PM, not 1 PM. During an observation on 11/13/23 beginning at 11:58 AM, revealed 28 residents and 8 nursing staff members were in the dining room. The first dining room tray was served at 12:18 PM. The last dining room tray was served at 12:52 PM. Several residents were overheard talking and complaining about meal trays always being served late. During an interview on 11/13/23 at 12:55 PM, CNA R stated meal trays were normally served late. CNA R stated there were plenty of nursing staff to help feed the residents and pass meal trays, but the kitchen staff was slow getting them out. During an observation on 11/13/23 at 1:01 PM, North Hall meal trays left the kitchen and were wheeled down to the hall. During an observation on 11/13/23 at 1:08 PM, South Hall meal trays left the kitchen and were wheeled down to the hall. During an observation on 11/13/23 at 1:10 PM, [NAME] Hall meal trays left the kitchen and were wheeled down the hall. During an interview on 11/13/23 at 1:15 PM, East Hall meal trays left the kitchen and were wheeled down to the hall. During an observation on 11/14/23 at 12:23 PM, the dietary staff started serving meal trays in the dining room. The last hall cart tray was served at 1:01 PM. During an interview on 11/15/23 beginning at 6:25 PM, [NAME] F stated residents had not complained about meals being served late, but other staff members had. [NAME] F stated dietary staff were responsible for making sure meals were served timely. [NAME] F stated it was important to ensure meals 455579 Page 31 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0809 were served on schedule, so it did not mess up the other staff members that have jobs to do. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 beginning at 6:28 PM, the DM stated he expected meals to be served at the scheduled time. The DM stated he was responsible for monitoring to ensure meals were served timely. The DM stated he was unaware of any complaints about the food not being served on time. The DM stated it was important to ensure the food was served timely to allow residents time to eat and so they did not go without food. Residents Affected - Many Record review of the dietary polices provided by the facility did not address meal serving times. 455579 Page 32 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. DA E wore a hair net while in the kitchen. 2. Paper towels were readily available at the handwashing sink. 3. Meat was thawing in the appropriate container and sink. 4. Food preparation areas were kept clean and free of crumbs and dirty dishes. 5. The refrigerator was kept at the appropriate temperature. 6. The refrigerator was not leaking condensation. 7. The refrigerator was free of foul-smelling rotting odors. 8. The containers in the refrigerator were labeled, dated, and not expired. 9. Eggs were not cracked. 10. The frozen packages in the freezer were labeled and dated. 11. The can opener tip, microwave, and fryer were kept clean. 12. The grease in the fryer was clean and see-through. 13. The bread was not molding. 14. Items in the dry storage area were labeled. 15. Sanitization buckets were at the appropriate sanitization level. 16. Personal items were kept off the food preparation area. These failures could place residents at risk for food-borne illness. The findings included: During the initial tour kitchen observation and interview with [NAME] F and Housekeeping Supervisor on 11/13/23 between 8:32 AM and 9:10 AM, the following was revealed: 1. DA E was walking out of the kitchen door with no hair net observed. DA E re-entered the kitchen, 455579 Page 33 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0812 with no hair net, to assist [NAME] F with the paper towel holder. Level of Harm - Minimal harm or potential for actual harm 2. The hand washing station had no paper towels readily available for use. Residents Affected - Many 3. [NAME] F stated the three-compartment sink was being utilized. [NAME] F stated the first sink near the hand washing station was the wash sink. There were several dirty pans stacked in the first sink with a crusted, dried yellow substance. [NAME] F stated the second sink was for rinsing the dishes and the third sink was for sanitization. There were 2 roasts thawing in the sanitization sink. The sink was full of water and water was running on top. [NAME] F stated the meat should not have been thawing in the sanitization sink. 4. The clean food preparation area had a dirty sheet pan with food crumbs on it. The preparation surface had multiple crumbs of various sizes. The food preparation area near the juice spigot had 3 half-filled juice glasses located on top of the microwave. There was a dirty tray with uncovered bowls of cereal. There were 2 large containers of spices located on top of a clean tray with clean plate holders on it. The Housekeeping Supervisor stated it was probably left from night shift staff because those spices were not used for breakfast. There was an opened package of biscuit mix on the shelves located above the stove. 5. Refrigerator #1 had a temperature of 44 degrees Fahrenheit. Normal temperature should be less than 41 degrees Fahrenheit. 6. Refrigerator #1 had leaking clear condensation onto a container of lemon wedges. The container was covered with plastic cling wrap. The cling wrap was sagging into the container and was not covering the container fully. There was a large amount of clear liquid in the container and on top of the cling wrap causing it to sag. 7. When Refrigerator #1 was opened, a foul-smelling rotting odor was noticed. [NAME] F noticed the smell. 8. Refrigerator #1 had a date of 11/03 on the container of lemons with no use by date. Refrigerator #1 had a container of cream of chicken with a use by date of 11/10. Refrigerator #2 had an undated and unlabeled container of chopped greens, 2 unlabeled packages of stacked, sliced deli meat, an unsealed and undated box of bacon, and one container of cheese slices that was opened on the corner slightly. 9. Refrigerator #2 had four stacks of egg crates with cracked eggs as evidenced by dark yellow, dried egg yolks observed on the outside of the crates. 10. Freezer #3 had four undated broccoli packages and one opened package of yellow squash. Freezer #4 had approximately four clear bags of an undated, unlabeled white cauliflower-looking vegetable. 11. The can opener blade had a thick, black, gel-like build up on the tip. [NAME] F stated the can opener should have been cleaned after every use. The microwave had multiple food stains and food debris on the inside. The fryer had grease stains on the outside of the fryer and on the side of the stove which was located beside the fryer. 12. The fryer inside surface had multiple blackish-brown crumbs of various sizes. The crumbs were also floating on the surface of the grease, which was black and solid, not see-through. 455579 Page 34 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0812 13. One package of hotdog buns had a bluish-green fuzzy mold-like substance on the side. Level of Harm - Minimal harm or potential for actual harm 14. The dry storage area had approximately six unopened, unlabeled bags of hotdog buns. There were approximately 10 bags of different unopened, unlabeled cereals located on the shelf. Residents Affected - Many 15. The sanitization bucket was located on top of the food preparation and serving area. The bucket was filled approximately 1/3 of the way with a brownish clear liquid and small debris floating on top. The test strip was performed and revealed no sanitization in the bucket. [NAME] F, DA E, and the Housekeeping Supervisor stated they had not prepared a sanitization bucket yet and that bucket was left over from the night shift. During a follow-up kitchen observation and interview with the RDO on 11/13/23 between 4:06 PM and 4:18 PM, the following was revealed: 1. Sanitization bucket #1 had a clear liquid inside and was filled approximately 1/3 of the way full. A test strip was performed, and no color was observed, which indicated no sanitization. The RDO poured the bucket out and re-did it. 2. A set of car keys was observed on the clean food preparation area. The RDO stated the keys should not have been on the table. 3. The RDO stated the three-compartment sink was not being utilized. The RDO stated the staff used it for rinsing and thawing but used the dishwashing area to clean the dishes. 4. The fryer had crumbs of various sizes floating on the surface of the grease, which was black and solid, not see-through. During an attempted interview on 11/15/23 at 6:07 PM to gather more information, DA E did not answer the phone call. A brief message was left with no return call upon exit of the facility. During an interview on 11/15/23 beginning at 6:09 PM, [NAME] F stated the dietary staff who were working was responsible for ensuring the kitchen was kept clean and sanitary. [NAME] F stated the food preparation area was supposed to have been cleaned after each meal. [NAME] F stated the dietary staff were not cleaning it well including her. [NAME] F stated there was not a schedule for routine cleaning on the grease in the fryer. [NAME] F stated the DM had been changing it once per week usually every Saturday. [NAME] F stated she did not work on Saturday, but it should have been cleaned. [NAME] F stated whoever used the fryer was supposed to clean it. [NAME] F stated she did not believe the night shift had cleaned it before they left. [NAME] F stated labeling and dating food items in the fridge, freezer, and dry storage area should have been completed when the truck came in. [NAME] F stated the opened date and when it expires should have been included on the food items. [NAME] F stated everyone was responsible for making sure items were labeled and dated. [NAME] F stated it was important to ensure items were labeled, dated, and not expired so the food did not get bacteria in it that could have made the residents sick. [NAME] F stated car keys should not have been in the food preparation area and dirty items should have been separate from the clean items. [NAME] F stated all staff were responsible for making sure personal items and clean and dirty areas were separated to prevent germs from spreading and cross-contamination. [NAME] F stated meat should have been thawed in the refrigerator. [NAME] F stated she had to thaw the meat in the sanitization sink because the meat was not set out the day before and there was not enough time to thaw it. [NAME] F stated it was important to ensure meat was thawed appropriately to prevent bacteria from contaminating the food. [NAME] 455579 Page 35 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many F stated she did not use any eggs for breakfast and did not realize there were any cracked eggs. [NAME] F stated cracked eggs should have been thrown away by any of the staff members that saw they were cracked. [NAME] F stated it was important to ensure they were discarded to prevent germs from getting in the eggs and spreading. [NAME] F stated she realized there were no paper towels but did not know where to find the key to replace them. [NAME] F stated it was important to have paper towels easily accessible to prevent re-contamination of the hands trying to find some. [NAME] F stated the temperature on the refrigerator should have been checked three times a day. [NAME] F stated on 11/13/23, she looked at the wrong temperature. [NAME] F stated she should have looked at the temperature on the thermometer in the fridge. [NAME] F stated if the temperatures were different, she should have let the manager know and moved the food to a different fridge. [NAME] F stated it was important for the temperatures to be correct to prevent bacteria from growing. [NAME] F stated it was important to ensure the kitchen was clean and sanitary to prevent cross contamination and food-borne illness. During an interview on 11/15/23 beginning at 6:17 PM, the RDO stated everyone was responsible for ensuring things were kept clean and sanitary. The RDO stated the DM should have been completing a daily walkthrough of the kitchen to ensure things were not missed. The RDO stated it was important to ensure the kitchen was kept clean and sanitary to prevent cross-contamination and food-borne illness or growth of bacteria. During an interview on 11/15/23 beginning at 6:28 PM, the DM stated he did not come into the facility on [DATE] until that evening. The DM stated he expect staff to clean as they went so nothing was left and staff did not forget. The DM stated he expected staff to ensure a hair net was always worn in the kitchen. The DM stated all food items should have been labeled, dated, and non-expired. The DM stated the dietary staff should have been using the temperature on the thermometer located inside the fridge. The DM stated if the fridge was the incorrect temperature, he expected staff to notify him and the RDO and they would have instructed them to move the items. The DM stated it was important to ensure the fridges were kept at the appropriate temperatures to prevent spoilage. The DM stated he expected all personal items to be kept out of the food service and preparation area. The DM stated the sanitization buckets should have been checked and changed every two hours and when dirty. The DM stated he expected the facility staff to ensure all areas were kept clean and sanitary. The DM stated it was important to ensure the kitchen was kept clean and sanitary to prevent cross-contamination and food-borne illness. During an interview on 11/15/23 beginning at 6:36 PM, the Administrator stated he expected dietary staff to ensure the kitchen was kept clean and sanitary. The Administrator stated the DM, then RDO was responsible for ensure the kitchen was kept clean and sanitary. The Administrator stated it was important to ensure the kitchen was kept clean and sanitary to ensure food was prepared under safe and sanitary conditions to prevent food-borne illness. Record review of the Food Safety and Sanitation Plan policy, revised 10/24/22, revealed .foods will be refrigerated at 41 F or below .all potentially hazardous foods must be thawed in such a way as to prevent bacterial multiplication on the surface .completely submerged under cold running water .discard all cracked eggs .sanitizing solution must be maintained at appropriate strength .must be changed routinely to ensure proper strength . Record review of the Equipment Cleaning Procedures policy, reviewed on 07/2022, revealed .equipment and items that are used in food preparation should be cleaned and sanitized after each use .if the fry is used frequently (five or more times a week), clean weekly .if grease is strained after each use, it extends the life of the grease .all equipment should be cleaned as needed. Equipment that 455579 Page 36 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many becomes soiled between scheduled cleanings must be properly cleaned and sanitized .temperature and humidity must be properly maintained and controlled to prevent condensation and the growth of molds .the DM will schedule routine cleaning of dietary equipment and the environment .each employe is responsible for cleaning up after themselves .food preparation areas and counter tops will be cleaned and sanitized throughout meal preparation, suing the clean as you go philosophy. A bucket of sanitizing solution at proper concentration will be utilized at workstations to store wiping clothes and prevent growth of microorganisms .solution will be changed as necessary . Record review of the Frozen and Refrigerated Foods Storage policy, reviewed 07/22/22, revealed .internal thermometer even if an external thermometer is present .temperatures should be check and logged a minimum of twice daily, once in the morning and once in the evening .temperatures outside the parameter should be reported to DM at time of discovery .refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened .items stored in refrigerator must be dated upon receipt .they must also be dated with an expiration date unless they have one from manufacture .packaged frozen items that are opened and not used in entirety must be properly sealed, labeled, and dated for continued storage .all refrigerated and frozen items in storage will contain a minimum label of common name of product and dated a noted above 455579 Page 37 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

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 observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #56) reviewed for infection control practices related to transmission-based precautions and 1 of 3 facility staff members (MA B) reviewed for infection control practices related to medication pass. Residents Affected - Some 1. The facility did not ensure Resident #56 had an order for isolation precautions and appropriate signage outside the door to alert staff and visitors of isolation status and appropriate PPE to wear inside Resident #4's room. 2. The facility did not ensure MA B disinfected the manual blood pressure monitor and stethoscope between Resident #52, #41 and #20. These failures could place residents at increased risk for infection or cross-contamination of communicable disease that could diminish the resident's quality of life. The findings included: 1. Record review of the face sheet, dated 11/15/2023, revealed Resident #56 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of MRSA (multi-drug resistant organism) and bacteremia (infection of the blood stream). Record review of the comprehensive MDS assessment, dated 11/01/2023, revealed Resident #56 had clear speech and was usually understood by staff. The MDS revealed Resident #56 was usually able to understand others. The MDS revealed Resident #56 had a BIMS of 14, which indicated he was cognitive intact. The MDS revealed Resident #56 had an active multi-drug resistant organism infection and was receiving IV antibiotic medication. Record review of the comprehensive care plan, dated 10/30/2023, revealed Resident #56 had an infection and the interventions indicated he was on contact precautions. Record review of the order summary report, dated 11/13/2023, revealed Resident #56 had no order for contact precautions. During an observation and interview on 11/13/2023 beginning at 10:29 AM, surveyor knocked on Resident #56's open room door and asked permission to enter. The room door was opened into the room and the outside of the door was not visible. Resident #56 gave surveyor permission to enter the room and Resident #56 had a PICC line observed to his right upper arm. There was an IV pole in the room with an empty pouch and tubing hanging off the pole. Resident #56 stated he was receiving antibiotics. Surveyor finished Resident #56's interview and turned to walk out of the room and noticed a blue bag hanging on the outside of the door with PPE supplies observed inside the pouches. There was no signage located on the door or outside the room to indicate resident was on contact precautions. Resident #56 stated the staff do wear the gowns and gloves in his room because of the infection on his leg. Surveyor searched the room for biohazard boxes, and they were located against the wall between to items of furniture. 455579 Page 38 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0880 Level of Harm - Minimal harm or potential for actual harm During an observation on 11/13/2023 at 4:22 PM, no signage was observed on Resident #56's door or outside of room to indicate resident was on contact precautions. During an observation on 11/14/2023 at 9:33 AM, no signage was observed on Resident #56's door or outside of room to indicate resident was on contact precautions. Residents Affected - Some During an interview on 11/15/2023 beginning at 4:49 PM, CNA H stated she knew Resident #56 was on contact isolation. CNA H stated she believed the signage had been on his door during the last week but was unsure because she did not pay attention to signage. CNA H stated signage to indicated isolation status were important to post so staff and visitors were aware of the infection and could prevent the spread of infection. During an interview on 11/15/2023 beginning at 4:57 PM, RN K stated she was unsure who was responsible for ensuring signage was placed outside residents' room who were on isolation precautions. RN K stated signage should have been posted outside Resident #56's room to alert staff and visitors he was on contact isolation. RN K stated the signage was important because it alerted staff and visitors the proper PPE to wear inside the resident's room. RN K stated an order should have been in the computer for contact isolation. RN K stated the admitting nurse should have placed the order in the computer. RN K stated it was important to ensure signage was posted outside the room to protect the residents, staff, and visitors from the spread of infection. RN K stated it was important to ensure an order was placed in the computer for contact isolation to establish the care of the resident. During an interview on 11/15/2023 beginning at 5:42 PM, the DON stated the charge nurse was responsible for ensuring orders for isolation precautions were placed in the computer. The DON stated there should have been an order for contact isolation precautions. The DON stated signage should have been placed on Resident #56's door to indicate the type of isolation and the appropriate PPE to wear inside the resident's room. The DON stated the signage and PPE supplies should have been visible from the hallway. The DON stated the ADONs were responsible for monitoring to ensure orders were placed in the computer. The DON stated nurse management was responsible for ensuring signage was located on the doors of resident's who were on transmission-based precautions. The DON stated it was important to ensure signage was located outside of the resident's room for the safety of residents and others and to prevent the spread of infection. The DON stated it was important to ensure an order was placed in the computer to ensure staff were aware of the isolation precautions. During an interview on 11/15/2023 beginning at 6:36 PM, the Administrator stated there should have been signage outside Resident #56's door if it did not violate his dignity. The Administrator stated he expected nursing to ensure orders were obtained for isolation precautions. The Administrator stated nursing management was responsible for monitoring to ensure signage was placed and orders were obtained for residents on transmission-based precautions. The Administrator stated it was important to ensure proper signage was placed outside the resident's room to ensure proper PPE was worn to prevent exposure to organisms. 2. During an observation and interview on 11/14/2023 starting at 7:55 a.m., MA B used the manual blood pressure monitor and stethoscope to check Resident #52's blood pressure. After using the manual blood pressure monitor and stethoscope, MA B placed the blood pressure monitor and stethoscope back in the bottom right drawer without disinfecting them. MA B administered Resident #52's medications. MA B took the manual blood pressure monitor and stethoscope from the bottom right drawer and checked Resident #41's blood pressure. After using the manual blood pressure monitor and stethoscope, MA B placed the blood pressure monitor and stethoscope back in the bottom right drawer without 455579 Page 39 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disinfecting them. MA B administered Resident #41's medications. MA B then took the manual blood pressure monitor and stethoscope and checked Resident #20's blood pressure. After using the manual blood pressure monitor and stethoscope, MA B placed the blood pressure monitor and stethoscope back in the bottom right drawer without disinfecting them. MA B administered Resident #20's medications. MA B stated she should have cleaned the manual blood pressure monitor and stethoscope between each resident. MA B stated she was nervous because the state surveyor was present. MA B stated it was important to disinfect between uses to prevent cross contamination. During an interview on 11/15/2023 at 2:15 p.m., the DON stated she expected MA B to disinfect the blood pressure cuff and stethoscope between each resident. The DON stated she was responsible for monitoring and overseeing by random spot checks 2-3 times a week. The DON stated she has not noticed any issues as such disinfecting the reusable resident care equipment. The DON stated it was important to disinfect between each resident to prevent any spread of infections. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated he expected the blood pressure cuff and stethoscope to be disinfectant between residents. The Administrator stated it was important to disinfect between residents to prevent a possible cross contamination or infection. Record review of the facility's policy titled Clinical Practice Guidelines: Cleaning and Disinfecting Portable Equipment dated 05/04/2021, indicated it is the policy of this facility to follow infection control principles to prevent spread of infection through contact with portable equipment in the resident's care environment . 2. Staff shall follow environmental infection control principles for cleaning and disinfecting the equipment. a. Each user is responsible for routine cleaning and disinfection b. Cleaning shall be performed daily and between residents Record review of the Transmission-Based (Isolation) Precautions policy, implemented 10/24/2022, revealed .an order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents .signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room .CDC category of transmission-based precautions ( .contact .) or instructions to see the nurse before entering will be included in signage . 455579 Page 40 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 2 residents (Residents #3) reviewed for antibiotic use. Residents Affected - Few The facility failed to assess and incorporate monitoring of antibiotic use for Resident #3. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #3's face sheet, dated 11/15/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis which included unspecified fracture of shaft of right fibula (broken leg), type 2 diabetes (blood sugar disorder) and heart failure (heart does not pump blood as good as it should). Record review of the MDS Resident Assessment Screening dated 09/21/2023 indicated Resident #3 was able to make self-understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated intact cognition. Record review of a care plan last revised on 10/03/2023 revealed Resident #3 was incontinent of bowel/bladder and the interventions included to monitor for s/sx of urinary tract infection. Record review of Resident #3's Order Summary Report dated 11/15/2023 revealed Azithromycin 500 mg, take 1 tablet by mouth one time with a start date of 11/08/23 thru 11/09/23, and Azithromycin 250 mg, take 1 tablet by mouth every day for pneumonia for 4 days with a start date of 11/09/2023 thru 11/13/23. Azithromycin 250 mg, take 1 tablet by mouth every day for pneumonia for 4 days with a start date of 11/12/2023 thru 11/16/23. Record review of Resident #3's Order Summary Report dated 11/15/2023 revealed ceftriaxone sodium injection solution reconstituted gm intramuscularly every day x3 days for respiratory infection with a start date of 11/07/2023 thru 11/10/23. Record review of Resident #3's McGeer's tool for the month of November revealed that the assessment was not completed for the Azithromycin or the ceftriaxone. During an interview on 11/15/23 at 4:09 PM, the DON stated the facility used the McGeer's tool to monitor antibiotic use. The DON stated the McGeer's was completed after the antibiotics were started and the facility had 7 days to complete the McGeer's. The DON stated the ADON was responsible for completing the McGeer's tool and she was responsible for making sure the ADON completed it. The DON stated the ADON's had been working on the floor and that was why they did not have time to complete the McGeer's tool on the resident. The DON stated she had only been at the facility for a month and did not know the process or the time frame of when the McGeer's tool should have been completed. The DON stated the importance of assessing and monitoring antibiotics was to make sure the facility met criteria and did not give anything unnecessary, to monitor tracking and trending, and to identify 455579 Page 41 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few true infections. The DON stated if antibiotic monitoring was not done then the facility could have missed tracking or trending on the hall or missed tracking urinary tract infections on the hall. During an interview on 11/15/23 at 5:04 PM, ADON C stated she was responsible for completing the McGeer's tool. ADON C stated the process was to complete the McGeer's tool the day she received the antibiotic for the resident. ADON C stated the process for monitoring antibiotics was to review the nurses note and get the s/sx of when the infection started and log it after the McGeer's tool was completed. ADON C stated she would then complete the stewardship and map it at the end of the month. ADON C stated she had not completed the McGeer's tool on resident for the month of November because she had been working the floor. ADON C stated there was another ADON that helped her when she was working, but she had been working on the floor as well. ADON C stated the DON was responsible for making sure the McGeer's tool was completed. ADON C stated the importance of assessing antibiotic use was to track and trend antibiotics and see if the resident had a true infection, what type of infection, and if residents were on certain halls. ADON C stated if antibiotics were not monitored, then they might not be able to determine a true infection. During an interview on 11/15/23 at 4:23 PM, the Administrator stated he expected the McGeer's tool to be completed and the DON and ADON's were responsible. The Administrator stated the DON was new and just learning the process in place, but the Regional Nurse consultant was to do more training to help with the system. The Administrator stated the importance of monitoring antibiotics was to ensure they were used correctly, the infections were meeting criteria, and had explanations as to why residents were taking the antibiotics. The Administration stated if the facility did not monitor antibiotics, then the antibiotic might not be working the way it was supposed to. Record review of a facility Antibiotic Stewardship policy last revised on 05/02/2019 indicated .Antibiotic Stewardship is part of our Infection Control Program, and the facility will track outcome measures of antibiotic usage. The facility will assess residents using standardized tools and monitor for adverse reactions/outcomes elated to antibiotic therapy 455579 Page 42 of 43 455579 11/15/2023 Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow their established smoking policy for 1 of 1 smoking area reviewed for smoking. Residents Affected - Few The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. This failure could place residents at risk for smoking-related injuries and fires in the facility. Findings included: During an observation on 11/13/2023 at 12:25 p.m., the designated smoking area had numerous cigarette butts laying on the ground. During an observation on 11/14/2023 at 3:27 p.m., the designated smoking area had numerous cigarette butts laying on the ground. During an interview on 11/15/2023 at 4:28 p.m., the Maintenance Manager stated the maintenance supervisor was responsible for monitoring the smoking area. The Maintenance Manager stated he was filling in for the maintenance supervisor since he was on vacation. The Maintenance Manager stated he had not been outside to the smoking area. The Maintenance Manager stated the cigarette butts should be disposed in the metal container. The Maintenance Manager stated it was important to ensure the cigarette butts was disposed in the metal container to prevent a fire. During an interview on 11/15/2023 at 4:39 p.m., the Administrator stated the maintenance director and environmental services were responsible for monitoring the smoking area. The Administrator stated he monitored and oversees by walking out the smoking area every morning. The Administrator stated he did not see any cigarette butts on the ground during his mornings walk through. The Administrator stated the cigarette butts should be disposed in an ash receptacle. The Administrator stated it was important to dispose cigarette butts correctly to prevent a fire. Record review of the facility's policy titled Smoking revised 07/14/2023, indicated it is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking 9. Patients may only smoke in designated center location . 455579 Page 43 of 43