Health inspection·August 17, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 08/16/2022 at 10:00 a.m., Resident #24 was alert in her bed, coughing, said she swallowed a toothpick. She was assessed by LVN A, he said she was fine. Resident #24 had on oxygen at 2 liters per nasal cannula and the oxygen tubing and humidifier was not dated or labeled. LVN A said he was not Resident #24's charge nurse and did not know anything about Resident #24's oxygen but advised the surveyor to ask Resident #24's charge nurse, LVN B. Residents Affected - Few During an interview and record review on 08/16/2022 at 10:19 a.m., LVN B said she was Resident #24's charge nurse. LVN B said she was an agency nurse but worked at the facility regularly and was familiar with Resident #24. LVN B said she did not know why Resident #24 required oxygen or what the physician order was but said she thought she had been treated for a pulmonary embolism in the hospital. LVN B said the oxygen was supposed to be transcribed onto the treatment administration record when the physician order was received, so the appropriate protocol could be documented such as monitoring the oxygen administration and changing tubing to ensure it was safe and clean. LVN B stated Resident #24's oxygen administration nor set up maintenance was documented on her medication or treatment administration records. During an interview and record review on 08/16/2022 at 10:30 a.m., the MDS nurse said she was one of the nurse managers responsible to review clinical records for newly admitted residents daily in the interdisciplinary team meetings. The MDS nurse said Resident #24 was on oxygen since admission and the physician order should have been transcribed onto her treatment administration order to ensure it was properly administered and maintained but it was missed. During an interview on 08/16/2022 at 11:43 a.m., the ADON said she contacted Resident #24's Nurse Practitioner to clarify her order for oxygen and it was transcribed into the computer to print on the consolidated physician's orders and the treatment administration orders after surveyor intervention. During an interview on 08/16/2022 at 10:37 a.m., the Administrator said the nurse managers were responsible to oversee that newly admitted residents' physician orders were properly transcribed into the clinical records, including the electronic medical records and treatment administration records, and the DON should have ultimately overseen that Resident #24's oxygen administration and set up were appropriately transcribed and administered. Record review of the facility's Oxygen Administration policy effective March 2019 indicated the facility required that a physician's order be obtained prior to the administration of oxygen. Record review of the facility's Comprehensive Interdisciplinary Plan of Care policy effective July 2018 indicated comprehensive interdisciplinary plan of care will be developed and implemented no later than 21 days following the admission, annual, or significant change MDS/RAI process. Procedures included review of the medical record documentation including, but not limited to, the following to establish functional and clinical needs: .nursing admission information, consider the following resident areas including but not limited to: unique characteristics . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 implement the comprehensive person-centered care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents reviewed for physician orders for oxygen therapy. (Resident #4) Residents Affected - Few The facility failed to implement a comprehensive person-centered care plan for Resident #24's oxygen at 3 liters nasal cannula as needed for shortness of breath ordered by the physician on 06/03/2022 and the oxygen tubing was not dated. These failures could place residents at risk for not receiving appropriate care and services to meet their needs. Findings included: Record review of the Physician orders dated 06/03/2022 indicated Resident #24 was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included bipolar disorder, pulmonary embolism, spinal stenosis, and chronic pain syndrome. Record review of Resident #24's physician orders dated 06/03/2022 indicated she admitted to the facility with an order for oxygen at 3 liter per minute as needed for shortness of breath. Record review of Resident #24's care plans initiated on 06/03/2022 indicated she was at risk for ineffective breathing pattern and approaches included to administer oxygen as ordered by the physician. Record review of Resident #24's treatment administration record dated 06/03/2022-08/31/2022 revealed she did not have documentation of her oxygen administration as ordered by the physician or oxygen set up maintenance. Record review of Resident #24's MDS dated [DATE] indicated she was cognitively intact and was dependent on one staff for activities of daily living and utilized oxygen. During an observation and interview on 08/15/2022 at 9:34 a.m., Resident #24 was resting in her bed with the head of her bed elevated, awake and alert, and had oxygen at 2 liters per nasal cannula on. She said she always required her oxygen since she admitted from the hospital and said she could not breath without it. Her oxygen tubing and humidifier was not dated or labeled. During an observation and interview on 08/16/2022 at 10:00 a.m., Resident #24 was alert in her bed, coughing, said she swallowed a toothpick. She was assessed by LVN A, he said she was fine. Resident #25 had on oxygen at 2 liters per nasal cannula and the oxygen tubing and humidifier was not dated or labeled. LVN A said he was not Resident #24's charge nurse and did not know anything about Resident #24's oxygen but advised the surveyor to ask Resident #24's charge nurse, LVN B. During an interview and record review on 08/16/2022 at 10:19 a.m., LVN B said she was Resident #24's charge nurse. LVN B said she was an agency nurse but worked at the facility regularly and was familiar with Resident #24. LVN B said she did not know why Resident #24 required oxygen or what the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician order was but said she thought she had been treated for a pulmonary embolism in the hospital. LVN B said the oxygen was supposed to be transcribed onto the treatment administration record when the physician order was received so that the appropriate protocol could be documented such as monitoring the oxygen administration and changing tubing to ensure it was safe and clean. LVN B confirmed Resident #24's oxygen administration or set up maintenance was documented on her medication or treatment administration records. During an interview and record review on 08/16/2022 at 10:30 a.m., the MDS nurse said she was one of the nurse managers responsible to review clinical records for newly admitted residents daily in the interdisciplinary team meetings. The MDS nurse said Resident #24 was on oxygen since admission and the physician order should have been transcribed onto her treatment administration order to ensure it was properly administered and maintained but it was missed. During an interview on 08/16/2022 at 11:43 a.m., the ADON said she contacted Resident #24's Nurse Practitioner to clarify her order for oxygen and it was transcribed into the computer to print on the consolidated physician's orders and the treatment administration orders after surveyor intervention. During an interview on 08/16/2022 at 10:37 a.m., the Administrator said the nurse managers were responsible to oversee that newly admitted residents' physician orders were properly transcribed into the clinical records, including the electronic medical records and treatment administration records, and the DON should have ultimately overseen that Resident #24's oxygen administration and set up were appropriately transcribed and administered. Record review of the facility's Oxygen Administration policy effective March 2019 indicated the facility required that a physician's order be obtained prior to the administration of oxygen .place oxygen delivery device in plastic bag, labeled with the date andresident/patient name . Record review of the facility's Comprehensive Interdisciplinary Plan of Care policy effective July 2018 indicated comprehensive interdisciplinary plan of care will be developed and implemented no later than 21 days following the admission, annual, or significant change MDS/RAI process. Procedures included review of the medical record documentation including, but not limited to, the following to establish functional and clinical needs: .nursing admission information, consider the following resident areas including but not limited to: unique characteristics . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were in locked compartments, and permit only authorized personnel to have access medications for 1 of 4 medication carts (C/D Hall Medication Cart) observed, for labeling and storage, in that: C/D Hall medication cart was left unlocked outside the nurse's station during meal service. This deficient practice could place residents at risk for harm and possible drug diversion. The findings were: Observation on 08/15/22 at 12:50 p.m. revealed the C/D hall medication cart, located in front of the nurse's station with the medication drawers facing the hallway was unlocked and accessible to anyone in the hall. No staff members were in the direct line of sight to medication cart, no staff members were in the nurse's station and two unidentified residents were outside of the dining room nearby within three feet of the unlocked medication cart. During an interview with LVN A on 08/15/22 at 12:50 p.m., LVN A stated he was responsible for the unlocked C/D hall medication cart, and it should have been locked when left unattended. LVN A stated he should not have left the medication cart unlocked and kept the keys on his person to keep unauthorized users from getting into the medication cart or medication room. LVN A said there were confused residents that could get in the unlocked medication cart and said that one of the residents within three feet of the unlocked medication cart was confused and had the potential to be hurt by taking medications in the medication cart not prescribed for her, which was dangerous. He said he attended the in-service training in orientation regarding keeping the medication carts secured but had forgotten. During an interview with the DON on 08/15/22 02:02 p.m., she said the medication carts should always be locked when staff was not using them for any amount of time due to confused residents could access the medications. She said she wrote LVN A up and if any staff made this mistake again, they would be fired because it was a serious safety risk to her residents. During an interview with the ADM on 08/17/22 at 10:37 a.m., she said she was notified by the DON the C/D hall medication cart, located in front of the nurse's station with the medication drawers facing the hallway was unlocked and accessible to anyone in the hall and said staff were in-serviced in response to the surveyor found the medication cart unlocked. The ADM said this was immediately addressed due to the seriousness of the potential outcome to her residents if a confused resident accessed the unlocked medication cart. Record review of the facility's policy titled Medication Storage effective December 2018 read in part: Medications, treatments, and biologicals are stored safely, securely and properly following manufacturer's recommendations or facility policy. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The procedure indicated, Only licensed nurses, the consultant pharmacist, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 locked or attended by persons with legal authorized access. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Some The facility failed to ensure cooking utensils and pans were clean of moisture, food particles and stored in a dry sanitary manner. This failure could place residents who ate meals prepared in the kitchen at risk of food being served in unsanitary conditions and for food-borne illnesses. The findings included: During an observation of the kitchen on 08/15/22 at 10:15 a.m., 5 medium and 3 small steam table pans, stacked on the lower shelf of a table, contained moisture, water, food particles and a thick glazed oily substance on the inside. During an interview with [NAME] D, on 08/15/2022 at 10:32 a.m., she said those pans were put up too soon. She said she did not wash those pans, but she was responsible for washing her own pots and pans. She said she does not know who washed the pans, but the pans should be put up dry and clean. During an interview with the Dietary Manager on 08/15/2022 at 10:37 a.m., she said the pans are wet. She said she had no explanation for it; the staff know pans are supposed to be put up dry. She said the cook was responsible for washing their own pans. The Dietary Manager immediately placed the pans in the three-compartment sink for re-washing. When shown the thick glazed oily substance, the Dietary Manager did not comment, she shook her head and continued to place the pans in the three-compartment sink. Record review of the facility's Nutrition Services Practice Manual, 7.21.1 - Sanitation: Standard Clean and Sanitizing, dated September 2018. #12. Wash dirty pots and pans and cooking utensils in the three-compartment sink. #12 d. Air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to prevent the development and the transmission of disease and infections for residents dining in the facility and 2 of 2 staff reviewed for infection control (LVN A and CNA C). Residents Affected - Some *CNA C did not perform appropriate hand hygiene or don a hair net when entering the kitchen during a meal service. *LVN A did not wash or sanitize his hands in between feeding Residents #37,#9, #39 and #8. *LVN A was observed eating during and between assisting Residents #37,#9,#39 and #8 with their meals. These failures could place residents at risk for cross contamination, infection, and decreased quality of life. Findings included: During an observation on 08/15/22 12:40 p.m., LVN A was observed feeding Resident #37 while feeding this resident, LVN A was observed sneaking and eating himself. LVN A never wash his hands after any bites of food he put into his mouth, he would pull his face mask down, sneak a bit of food pull his mask back up over his mouth and nose and resume assisting Resident #37 with feeding. LVN A began to assist Resident #9 never washing or sanitizing his hands between residents. LVN A began to assist feeding Resident #39 never washing or sanitizing his hands between residents, then began assisting Resident #8 with feeding, never washing or sanitizing his hands. During an observation on 08/15/22 12:48 p.m. CNA C entered the kitchen during meal service to obtain a meal tray for a resident not eating in the dining room. She did not perform hand hygiene before she entered the kitchen and did not don a hair net, retrieved the tray from the central serving table in the kitchen, then took the tray outside of the kitchen in the dining room and obtained tea in an uncovered open Styrofoam cup and carried it down the C-hall to the resident's room. She left the resident's room and did not wash/sanitize her hands. During an observation on 08/15/22 12:40 p.m., LVN A was observed feeding Resident #37 while feeding this resident, LVN A was observed sneaking and eating himself. LVN A would remove his mask take a couple of bites of bread never wash his hands after any bites of food, pull his mask back up over his mouth and nose and resume assisting Resident #37 with feeding never washing or sanitizing his hands between residents. LVN A began to assist Resident #9 never washing or sanitizing his hands between residents. LVN A began to assist feeding Resident #39 never washing or sanitizing his hands between residents, then began assisting Resident #8 with feeding, never washing or sanitizing his hands. During an interview on 08/15/22 at 12:52 p.m. CNA C said the facility's protocol was for all staff must sanitize their hands and wear a hair net anytime they enter the kitchen past the door. CNA C said she did not think cups required covers when transported down the hall but then stated glasses were usually covered with saran wrap when delivered as part of infection control protocol to keep items residents would consume from contamination. CNA C stated she entered the kitchen inappropriately and did not observe the facility's protocol properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 08/15/22 at 2:02 p.m., the DON said staff were not allowed in the kitchen without hair nets or washing hands. During an interview on 8/16/2022 at 10:17 AM, the DON said staff should wash or sanitize hands between any patient contact and should not be eating while feeding any resident. She said the residents were at risk of infection from staff eating during contact and staff not washing or sanitizing hands between patient contact. During an interview on 08/17/22 at 10:37 a.m., the ADM said all staff were required to sanitize their hands and don hair nets when entering the kitchen so as not to contaminate food consumed by the residents. Record review of the facility's Sanitation policy effective September 2018 indicated the purpose of personal hygiene in the nutritional services department was to ensure proper personal hygiene to prevent contamination of food. The policy indicated the facility procedure for personal hygiene included to wash hands properly and as often as need, and .to wear a hair restraint at all times in the nutritional services department. Record review of a facility's policy, Personal Hygiene with a revised date of September 2018 indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Wash hands after the following activities, including, but not limited to: After touching the hair, face or body Resident/patient contact FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455910 If continuation sheet Page 9 of 9