Health inspection·February 21, 2025

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents unopened for the entire facility reviewed for resident rights. Residents Affected - Some The facility failed to ensure that residents received packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life. The findings included: During a confidential resident group meeting 02/19/25 at 02:13 PM, 10 confidential residents stated they had received mail and packages that had been opened by staff. They stated mailed was not delivered daily and there was no set schedule. They stated sometimes the mail was just placed in their rooms and they were not aware they had received a letter or a package. Residents stated they felt that it was a violation of their rights for their mail and packages to be opened and gone through. They stated no staff had ever asked them if they could open their mail nor had they been present while staff opened their mail. During an interview on 02/20/25 at 02:50 PM, the AD stated she delivered the mail daily. She stated she never opened residents mail but if a resident received a package, she took it to the ADON who opened it to ensure that the resident had not ordered anything that they were not allowed to have, such as medications or tobacco products. During an interview on 02/20/25 at 03:11 PM, the ADON stated packages were brought to his office before delivered to the residents because there could be medication in them. He stated he did not open boxes unless he knew they contained medications. During an interview on 02/20/25 at 03:19 PM, the DON stated he was unsure as to who was responsible for passing out mail. He stated he was unaware of any residents' mail or packages being opened. He stated no residents mail should ever have been opened unless approved by the resident and the resident was present. The DON stated it was a violation of resident rights to open any mail or packages. During an interview on 02/21/25 at 09:26 AM, the ADMN stated mail should have been delivered daily by the activity director. He stated residents mail should have never been opened without the resident's permission. He stated he was not notified of packages being opened. Admin stated it was a violation of resident rights to open and look at any mail. He stated he did not know what lead to the failure. Page 1 of 6 455957 455957 02/21/2025 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0576 Level of Harm - Minimal harm or potential for actual harm Review of facility document titled, Statement of Resident Rights, not dated, revealed in part: You, the resident, do not give up any rights when you enter a nursing facility .You have the right to .17) Receive unopened mail and to receive assistance in reading and writing correspondence . Residents Affected - Some 455957 Page 2 of 6 455957 02/21/2025 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure pharmacy procedures were followed for 1 of 4(200 Hall Medication Cart) medication carts, and 2 of 2 medication refrigerators reviewed for pharmacy services. The facility failed to remove expired medications from the 200 Hall Medication Cart. The facility failed to document monitoring of temperatures in the medication storage refrigerators in the medication room. These failures could place residents at risk of receiving ineffective therapeutic doses. The findings include: An observation on 02/19/25 at 11:45 AM of the 200 Hall Medication Cart revealed that the bottom drawer contained a bottle of a liquid oral supplement that was marked as opened on 06/01/24 and expired 07/27/2024 per date on the bottom of the bottle per manufacturer. In an interview on 02/19/25 at 11:48 AM with RN A, who was using 200 Hall Medication Cart, stated that the bottle should have been checked and discarded way before now. She further stated there are no patients on 200 Hall at this time with orders for this supplement. She stated it was the expectation of the staff to review supplies on the cart daily to verify nothing was expired. She also stated expired medications or supplements that are given to patients could result in making a resident sick or resident may not receive the therapeutic dose they need. In an interview on 02/19/25 at 03:48 PM with DON, stated the expectation of the medication cart and expired medications was to not have any. He stated he and the ADON are always going through them and have a pharmacy consultant that comes and audited the facility. He stated he was amazed there was anything expired, and an adverse outcome could be the resident would get sick or the medication could be ineffective. In an observation on 02/20/25 at 09:20 AM of the medication room revealed 2 temperature logs have not been completed since 02/12/25 for 2 refrigerators. Refrigerator #1 stored lab draws and urine specimens that must be refrigerated while waiting to be picked up, current temperature on thermometer shows 36 degrees and there was currently 1 urine specimen for pick up. Refrigerator #2 contained medications (such as inhalants for breathing treatments, suppositories, and some narcotics which have a secondary lock) that must be refrigerated and current temperature on thermometer shows 38 degrees. In an interview on 02/20/25 at 09:22 AM with RN B stated the temperature logs for the refrigerators are to be completed every day but she was not sure why it was not done since 02/12/25. She further stated the DON oversaw that they are completed. She stated an adverse outcome would be the medication would probably be ineffective or make a resident sick. In an interview on 02/20/25 at 09:30 AM with DON stated his expectations for the refrigerator temperature logs in the medication room was for the temperatures to be checked and logged every night and it was the night nurse's job. He stated an adverse outcome would be defective medications or labs ruined that were collected and waiting for pick up. 455957 Page 3 of 6 455957 02/21/2025 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0755 Record review of the facility policy titled VIII. Storing Drugs, undated, reflected [in-part]: Level of Harm - Minimal harm or potential for actual harm Procedures: 6. Drugs are to be store at proper temperatures. Drug storage conditions are defined as follows: Residents Affected - Some Temperature Range Storage Condition Celsius Fahrenheit Refrigerated 2-8 36 - 46 7. Drugs requiring refrigeration are kept in the refrigerator in the locked medication room and kept separate from other items. 8. Drugs are not to be kept on hand after the expiration date which appears on the label. Outdated, contaminated, or deteriorated drugs, and those in containers which are cracked, soiled or without secure closure are to be immediately withdrawn from stock, re-ordered from the pharmacy if a current order exists for it, and disposed of in accordance with the procedures for drug destruction. 455957 Page 4 of 6 455957 02/21/2025 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

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. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator and dry storage This failure could place residents that eat out of the kitchen at risk for foodborne illnesses. Findings include: During an observation of dry storage on 02/19/2025 at 09:10 AM revealed the following: *2 large plastic containers with label-powder milk with no use by date, *One bag of light brown in color, appeared to be crushed breadcrumbs sealed bag no label or date, *1 bag egg noodles in plastic zip bag with no used by date, *1 bag spaghetti noodles in plastic zip bag no used by date, *1 box lasagna noodles in plastic bag with no used by date, *1 bag vanilla wafers in zip lock with use by date 10/23, *8 packages vanilla wafers with no label or dates, *1 box powdered sugar open with no dates, *1 bag coconut flakes in a box with plastic bag not sealed or labeled. During an observation three door refrigerators on 02/18/2025 at 09:30 AM revealed the following: *1 open 1/2 box bacon slices not sealed or dated. *1 1/2 empty grape jelly jar with lid on, not dated or labeled. *1 carton approximately half full (40-ounce box) thickened sweet tea opened with no open date or use date. * 4 cartons of thickened sweet tea unopened. During an interview on 02/18/2025 at 10:00 AM the DM stated all products should have a received date and used by date. She stated some products have a used by date and that should be circled. The DM stated the potential harm to residents would be food poising, diarrhea, sickness, bacteria on food. The DM stated the failure occurred due to staff not paying attention. 455957 Page 5 of 6 455957 02/21/2025 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/21/2025 at 09:10 AM the ADMIN stated his expectations was all products in the kitchen be labeled and dated correctly. The ADMIN stated he did spot checks periodically in kitchen to be sure everything was working in kitchen. The ADMIN stated if residents were served out of date food products it could result in stomach aches, diarrhea, cause them to get sick. The ADMIN stated it was the responsibility of the DM to ensure all products are labeled correctly. Residents Affected - Many During a telephone interview on 02/21/2025 at 09:21 AM the Dietician with contracted dietary services, stated all products should be dated with date received and once a product was opened, it was dated with used by date. The Dietician stated potential harm to resident could be it could cause illness and contain bacteria. The Dietician stated she comes to facility once every 6 weeks to monitor kitchen staff and ensure products are labeled and dated. The Dietician stated the DM was new and was trying to educate kitchen staff on labeling and dating food products. Review of facility's policy titled: Food Storage-Dry Goods It is the center policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code . Review of facility's policy titled Food Storage: Cold dated October 2019 revealed: It is the center policy to ensure all time/Temperature control for Safety (TCS), frozen and refrigerated foods items, will be appropriately stored in accordance with guidelines of the FDA Food Code. 5. The Dining Services Director Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . 455957 Page 6 of 6