Health inspection·May 31, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids 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 parenteral fluids were administered with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident #60 and Resident #220) reviewed for IV therapy. Residents Affected - Some 1. The facility failed to provide adequate maintenance of the PICC line for Resident #60 by not performing a dressing change from 05/12/23 until either 05/26/23 or 05/29/23 (actual dressing change date unclear due to conflicting evidence). 2. The facility failed to provide adequate maintenance by not flushing the IV line, not performing dressing changes, and did not document insertion or removal or IV lines for Resident #220. These deficient practices could result in residents not receiving needed care to maintain optimum health and placing them at risk for infection and/or deterioration in their condition. Findings include: 1. Record review of Resident #60's electronic face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #60 had diagnoses which included Methicillin Susceptible Staphylococcus Aureus Infection (infection in the blood stream) and Cellulitis (skin infection) of right and left lower limb. Record review of Resident #60's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated no cognition impairment. Further review revealed Section O 0100. Special Treatment, procedures, and program. H: IV medications while a resident was coded-yes. Record review of Resident #60's Comprehensive Care plan, initiated 05/17/23, revealed no evidence or the resident receiving IV antibiotic therapy or having a PICC line. During an observation and interview on 05/30/23 at 1:24 PM, Resident #60 stated he received IV antibiotic therapy for a blood infection. He stated the PICC line dressing had not been changed until 05/29/23. Observation of the PICC line revealed the dressing was dated 05/25/23. Record review of Resident #60's nurses note, dated 05/12/23 at 10:25 AM, signed by LVN D, revealed Chest X-ray to verify PICC placement. PICC line in place. Record review of Resident #60's physicians orders, from 05/11/23-05/30/23, revealed no evidence of Page 1 of 13 455961 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0694 Level of Harm - Minimal harm or potential for actual harm and order for PICC line placement or dressing changes. Physician's orders revealed: Cefazolin (antibiotic) Intravenous Solution 2 GM/100ML every 8 hours with a start date 05/12/23 and end date 05/23/23 and Cefazolin Intravenous Solution 2 GM/100ML every 8 hours with a start date 05/23/23 and end date 06/08/23. Physician's orders revealed: Sodium Chloride (saline) flush each lumen (port) with 10 ml prior and post administration of IV cefazolin to keep line patent with a start date of 05/21/23. Residents Affected - Some Record review of Resident #60's MAR and TAR, from 05/11/23-05/30/23, revealed no evidence of PICC line dressing change being performed. Record review of Resident #60's nurses notes, from 05/11/23-05/28/23, revealed no evidence of PICC line dressing change being performed. Record review of Resident #60's nurses note, dated 05/29/23 at 3:00 PM, signed by LVN E, revealed: .PICC dressing changed with sterile technique this shift. 2. Record review of Resident #220's electronic face sheet, accessed 05/30/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #220 had diagnoses which included chronic kidney disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) dependence on renal dialysis, and Diabetes Type 2. Record review of Resident #220's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated no cognition impairment. Further review revealed Section O 0100. Special Treatment, procedures, and program. H: IV medications was coded-yes. Record review of Resident #220's Baseline Care Plan, dated 05/23/23, revealed no evidence of an IV line or antibiotic therapy. Record review of Resident #220's Comprehensive Care plan, initiated 05/24/23, revealed no evidence of the resident receiving IV antibiotic therapy or having an IV line. Record review of Resident #220's Admit Evaluation, dated 05/22/23, signed by LVN A, revealed no evidence of an IV line. Record review of Resident #220's Admit note, dated 05/22/23 at 8:54 PM, signed by LVN A, revealed no evidence of an IV line. Record review of Resident #220's physicians orders, from 05/22/23-05/31/23, revealed no evidence of an order to initiate an IV line, to flush an IV line, or for dressing changes to IV line. Further review of physician's orders revealed: Ceftriaxone (antibiotic) intravenous solution 2 GM intravenously every 24 hours with a start date of 05/26/2024 and end date of 05/30/23. Record review of Resident #220's nurses notes, from 05/22/23-05/28/23, revealed no evidence of IV-line insertion, removal, flushing, or dressing change. Record review of Resident #220's nurses note, dated 05/29/23 at 23:29 PM, signed by LVN E, revealed: IV start per protocol with 22g/1in in style to right AC with 2 attempts During observation and interview on 05/30/23 at 11:30 AM, Resident #220 stated he received IV 455961 Page 2 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antibiotic therapy. He stated he had his IV line when he was admitted . Observation revealed IV line to right AC (bend of arm) with dressing dated 05/20/23. During an interview on 05/31/23 at 3:30 PM, LVN A stated she was aware Resident #220 received IV antibiotic therapy. She stated he had an IV line to his right AC. She stated she never inserted an IV line in for Resident #220 and she did not know when it was done. LVN A stated the only way she would know a resident had an IV line was from hand off report she received from the previous nurse. LVN A stated the nurse on duty was responsible for entering all orders for new admissions and any received after. She stated he did not have an IV order at the time of admission, and she did not know who received the IV order. LVN A stated she was the nurse on duty the day Resident #220 was admitted . She stated she did assess Resident #220 and he did not have an IV line. LVN A she had never performed a PICC line dressing change on Resident #60. During an interview on 05/31/23 at 3:46 PM, the DON stated she knew Resident #60's dressing change was within the last 7 days because she verified it yesterday. She stated she was unsure the date of the dressing change. The DON stated there should have been on order for dressing changes. She stated not performing routine dressing changes could lead to infection. The DON stated Resident #220 had multiple IV lines inserted because he kept pulling them out. She stated there was no way he had the same IV line since 05/20/23. Resident #220 did not have an IV line at this time because IV antibiotic therapy was completed on 05/30/23. The DON did not know why none of this was documented. The DON stated the nurse on duty was responsible for entering all orders upon a resident's admission and any new orders. She stated not having the orders did not affect the residents care because the facility nurses communicated well during hand off report. The DON stated the failure ultimately occurred because she had not reviewed charts and orders. The DON stated she was going to review charts on Monday, but the State Surveyors entered, and she was busy. The DON stated the facility did not have any central lines and did not provide a policy for central line catheters. An interview was attempted with LVN E by phone, on 05/31/23 at 4:30 PM, however, the LVN was unavailable for interview. Record Review of the facility policy tilted, Intravenous Therapy implemented 03/20/21, revealed: Policy: The facility will adhere to accepted standards of practice regarding infusion practices. Compliance Guidelines .8. IV sites are changed every 72 hours, unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibit signs and symptoms of phlebitis.9. In the event and IV is left in place longer than 72 hours, IV site care will be done every 24 hours .12. A doctor's order is obtained before starting IV therapy. 13. IV sites are checked every four hours and as needed. 14. IV documentation is recorded in the nurses notes and or medication administration record. 455961 Page 3 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #220) reviewed for dialysis. Residents Affected - Few The facility failed to ensure Resident #220 had orders to receive dialysis, to monitor the dialysis access site, or to monitor post-dialysis for any signs or symptoms of infection or bleeding, edema, blood pressure, or fluid overload. This failure could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings include: Record review of Resident #220's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) dependence on renal dialysis, and Diabetes Type 2. Record review of Resident #220's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated no cognition impairment. Further review revealed Section O 0100. Special Treatment, procedures, and program. J: dialysis was coded-yes. Record review of Resident #220's Baseline Care Plan, dated 05/23/23, revealed: Medical Condition: G. Dialysis- Yes. G1. Dialysis care. A. check dialysis site every shift. Record review of Resident #220's Comprehensive Care plan, initiated 05/24/23, revealed no evidence or the resident receiving dialysis services. Record review of Resident #220's electronic physician order revealed no evidence of orders to receive dialysis, to monitor the dialysis access site, or to monitor post-dialysis for any signs or symptoms of: infection or bleeding, edema, blood pressure, or fluid overload. Record review of Resident #220's Admit/Readmit Evaluation, dated 05/22/23, revealed no evidence of a dialysis access site. Record review of Resident #220's nurses notes dated 05/22/23-05/31/23, revealed no evidence of monitoring the dialysis access site or monitoring post-dialysis for any signs or symptoms of infection or bleeding, edema, blood pressure, or fluid overload. There was no evidence of Resident #220 leaving the building to go to dialysis treatments. Record review of Resident #220's Admit/Readmit note, date 05/22/23 at 8:54 PM, signed by LVN A, revealed no evidence of Resident #220 receiving dialysis treatment or having a dialysis access. Record review of Resident #220's nurses notes, dated 05/23/23 at 1:51 PM, 05/25/23 at 2:58 PM, and 455961 Page 4 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0698 Level of Harm - Minimal harm or potential for actual harm 05/29/23 at 2:26 PM, signed by LVN B, revealed: .Dialysis catheter is present, catheter is clamped. Has a dialysis fistula/shunt in the right arm, has a bruit/thrill present Record review of Resident #220's nurses notes, dated 05/30/23 at 9:59 PM, signed by LVN A, revealed: .Resident is not on dialysis Residents Affected - Few During observation and interview on 05/30/23 at 11:30 AM, Resident #220 stated he received dialysis treatments. He stated no staff member had ever looked at his dialysis site. Resident #220 stated he could not remember ever having a nurse do an assessment on him before or after he received his dialysis treatment. He stated he did not have a fistula or shunt in his arm yet because he had only been receiving treatments for 5 weeks. Observation revealed dialysis access catheter to right upper chest. The 2 ports of the catheter were clamped with no date on the dressing. There was no fistula or shunt in either arm. During an interview on 05/31/23 at 3:30 PM, LVN A stated she was aware Resident #220 received dialysis treatments. She stated he had an access site to his right upper chest. LVN A stated she did not know why she documented Resident #220 was not on dialysis. She stated it was a mistake. LVN A stated the only way she would know a resident received dialysis and had an access site was from hand off report she received from the previous nurse. LVN A stated the nurse on duty was responsible for entering all orders for new admissions. LVN A stated she was the nurse on duty the day Resident #220 was admitted . She stated she did assess Resident #220 and she must have forgotten to document the dialysis access site on the admit note. LVN A stated she thought she entered the dialysis order into the computer. During an interview on 05/31/23 at 3:46 PM, the DON stated there was no specialized monitoring for dialysis. She stated the dialysis center monitored Resident #220's access site when treatment was provided. She stated there were no required orders for monitoring. She stated there was no need to monitor specifically for dialysis complications. The DON stated she was not aware Resident #220 did not have an order in the computer for dialysis treatment. She stated there should have been and order for dialysis treatment in the computer. The DON stated the nurse on duty was responsible for entering all orders upon a resident's admission. The DON stated dialysis was addressed on Resident #220's Baseline Care Plan and his Comprehensive Care Plan had not been completed due to him being a new admission. She stated not having the orders did not affect Resident #220's care because the facility nurses communicated well during hand off report. The DON stated the failure ultimately occurred because she had not reviewed charts and orders since Resident #220's admission. The DON stated she was going to do review charts on Monday (05/29/2023), but the State Surveyors entered, and she had been busy. The DON stated the facility did not have a dialysis policy to provide. 455961 Page 5 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order for one of two residents (Resident #46) reviewed for unnecessary medications. The facility failed to ensure Resident #46 did not have an order for the psychoactive medication diazepam (Valium) PRN for more than 14 days, without an evaluation by Resident #46's physician for the appropriateness of the medications. This failure could place residents at risk for receiving unnecessary medications. The findings were: Record review of Resident #46's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had a BIMS score of 99 out of 15, which indicated the resident was unable to complete the interview. Resident #46's had diagnoses which included Schizophrenia (a mental condition that causes the resident to interpret reality abnormally), mini strokes, Parkinson's (a brain disorder that causes uncontrollable movements), and Marasmic Kwashiorkor (kwashiorkor is predominantly a protein deficiency, while marasmus is a deficiency of all macronutrients - protein, carbohydrates, and fats.) Record review of Resident #46's physician's order, dated 03/14/23, revealed an order for Diazepam suspension 5mg/0.5mL every 4 hours as needed for anxiety. The end date indicated indefinite with no documented rationale. Physician's order dated 03/13/23 for Diazepam gel 10mg/mL every 4 hours as needed for anxiety. The end date indicated indefinite with no documented rationale. Record review of Resident #46's Medication Administration Record for March 2023 through May 2023 revealed Resident #46 received four as needed doses of diazepam (Valium) suspension 5mg/0.5mL on 03/31/23 at 8:09 PM, 04/07/23 at 5:02 PM, 04/14/23 at 10:02 PM, and 04/21/23 at 12:18 AM for anxiety. During an interview on 05/31/23 at 05:15 PM, the Administrator stated her expectations for renewing antipsychotic medications was the renewals got done. The Administrator stated the DON was responsible for monitoring to ensure renewals were done prior to the 14-day timeframe. The Administrator also stated she was ultimately responsible and did not have an answer for why the failure occurred. During an interview on 05/31/23 at 05:22 PM, LVN I Charge Nurse stated PRN antipsychotic medications should be renewed every 14 days. She stated all nurses were responsible for monitoring when renewals were due, even if ordered by hospice. LVN I stated the cause of the failure to renew a PRN antipsychotic medication may be due to a resident not receiving the medication for a while, the nurses overlook it. Record review of the facility's policy titled Psychotropic Medication, review date 1/8/2021, revealed: Policy It is the facility's policy that each resident's drug regimen is free from unnecessary 455961 Page 6 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0758 Level of Harm - Minimal harm or potential for actual harm drugs, including unnecessary Psychotropic drugs. Procedure/Process item 5. PRN orders for Psychotropic drugs are limited to 14 days, except if the prescribing practitioner document appropriate diagnosis and rationale to continue beyond 14 days. Then he/she must document the rationale in the resident's medical record and writes a new PRN prescription every 14 days after the resident has been evaluated. Residents Affected - Few 455961 Page 7 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 meal reviewed. The facility failed to follow the recipe when preparing the mechanical soft hamburger patty. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings include: Observation on 05/29/2023 between 11:30 AM and 1:00 PM, of the kitchen revealed [NAME] F added an unmeasured scoop of mayonnaise to the hamburger patties while she had chopped the cooked hamburger patties. Once prepared, the patties mixed with mayonnaise were plated and carried out to the dining room to be served to residents. During an interview on 05/29/20223 at 12:00 pm, [NAME] F stated she worked in kitchen for 13 years and she was taught to put mayonnaise in the mechanical soft meat to help hold it together on the bun. [NAME] F stated she had never looked at the recipe. During an interview on 5/29/2023 at 1:10 PM, the DM stated staff should have used the recipes. The DM stated mayonnaise should not have been added because the recipe did not call for mayonnaise. The DM stated altering recipes could have caused residents' to not receive their nutritional needs. The DM stated she had only been the DM since last week and felt staff were not trained properly by previous DM. During an interview on 05/31/2023 at 4:45 PM, the ADMN stated her expectation was for the cooks to follow the recipes. The ADMN stated what led to failure was the kitchen staff were in the middle of leadership transition and there were some staff that where not happy with the transition. The ADMN stated the effect on residents was they did not receive their correct nutritional needs and their preferences may have not been honored. The ADMN stated the cooks and the DM were responsible to ensure recipes were followed and ultimately it fell on ADMN. Record review of the facility's menu titled Beef Patty 4/1 on Bun dated 2/16/2023 revealed 5 mech soft step 1: per standard portion, process one piece of meat to a ground consistency. 6 mech soft step 2: combine ground meat with 1 tb per portion of *appropriate thickened low sodium beef broth for moisture. *mech soft thickened broth: for each 4 fl oz liquid add 1 tbsp thickener (corn starch based) HACCP: hold food at 135° f (57° c) or higher. 7 mech soft step 3: standard portion: serve 4 fl oz (#8 dipper) of ground meat mixture in between a soft bun/rolubread slices per recipe. serve with additional condiments/sauces per menu at time of service. Record review of the facility's polity titled, Diets, Nutrition and Hydration dated 3/2016 revealed, The facility will provide each resident with three meals daily and a nourishing snack at bedtime. Each meal will be provided according to physician orders, Facility Diet Manual, and menu spread sheet. 455961 Page 8 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 3 of 10 residents (Residents #1, #26 and #8) reviewed during the lunch meal. The facility failed to ensure Resident #1, Resident #26 and Resident #8 received a dessert or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Observation on 05/29/2023 between 11:30 AM and 1:00 PM, revealed Resident #1, Resident #26 and Resident #8 did not receive a dessert with their meal. Record review of Resident #1's face sheet, dated 05/31/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with original admission date of 01/05/1999 with following diagnosis abnormal weight loss, anorexia and dehydration. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed: Section C: Cognitive PatternsBIMS 99, which indicated severe cognitive impairment. Record review of Resident #8's face sheet, dated 05/31/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE], with original admission date of 07/13/2020 with following diagnosis Dementia and Type 2 Diabetes Mellitus without Complications. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed in Section C: Cognitive PatternsBIMS 13, which indicated the resident was Cognitively intact. Record review of Resident #26 face sheet, dated 05/31/2023, revealed a [AGE] year-old female admitted on [DATE], with original admission date of 12/26/2018 with following diagnosis Type 2 Diabetes Mellitus, Nutritional deficiency, and Unspecified Protein- Calorie Malnutrition. Record review of Resident #26's Quarterly MDS dated [DATE], revealed Section C: Cognitive PatternsBIMS 13(Cognitively intact) During an interview and observation on 05/29/2023 between 12:45 PM and 1:00 PM Resident # 26 stated he would like to get his lunch like everyone else at his table. After Resident#26 received lunch, he stated he would like to have dessert like the other residents around him. During an interview on 05/29/23 at 12:55 PM Resident #8 stated he did not receive a dessert and would like to have his dessert. During an interview on 05/29/2023 at 1:10 PM, the DM stated she had started in this position last week and was working under corporate Dietary Managers. The DM stated the menu should have been followed and residents should have received their entire meal, including dessert. The DM stated not 455961 Page 9 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0803 receiving their entire meal could have affected residents by not having their nutritional needs met. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/31/2023 at 11:45 AM, DS H stated she had forgotten to serve dessert to Resident #1, Resident #26, and Resident #8, but did not realize it until the next day when she was told by the DM. [NAME] H stated the nurses usually checked trays, but it was a crazy day and that led to failure of items being forgotten. Residents Affected - Some During an interview on 05/31/2023 at 4:45 PM, the ADMN stated her expectation was residents received all the food that was listed on the menu, unless they had requested a change. The ADMN stated what led to failure was the kitchen was in the middle of transition and there were some staff that where not happy with the transition. The ADMN stated the effect on residents could have been residents would not have received the nutrition needed, and their preferences not being met. The ADMN stated the cook and the DM were responsible to ensure residents received their entire meal and ultimately it fell on the ADMN. Record review of posted menu on 05/29/2023 revealed hamburger or hot dog, tater tots and chocolate chip cookie. Record review of the facility policy titled, Menus and Nutritional Adequacy, dated 05/30/2021, revealed Menus are planned to meet the average resident's nutritional needs . All menu changes will be reviewed and approved by the facility's Dietitian or Consultant Dietitian. When making menu changes it is important to make sure all food groups are represented in adequate numbers, and that menu changes are extended for all therapeutic diets per the facility diet manual. 455961 Page 10 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. 2. The facility failed to ensure all food was not past the expiration date. 3. The facility failed to ensure staff utilized proper personal hygiene practices. 4. The facility failed to ensure dietary staff cleaned kitchen counters between pureeing different foods. These failures could place residents at risk for food borne illnesses. Findings include: Observations on 05/29/23 between 10:20 AM and 10:50 AM of the kitchen revealed the following: Refrigerator #1 1. A container of raw chicken was dated 5/20. 2. 3 tubes of hamburger meat had a date of 5/19. 3. 1 plastic bag containing sliced yellow cheese was not sealed. 4. A box of frozen shakes that did not have an open date but had a manufacture label that stated may leave unfrozen for less than 14 days. Dry Storage 1. A container of thickener was not labeled with a date and item description. 2. A container of sugar was not sealed, and not labeled with a date and item description. 3. A container of flour was not labeled with a date and item description. 4. A plastic bag contained croissants were not labeled with a date and item description. 5. A plastic bag with a seal that contained a peanut butter and jelly sandwich was dated 5/19. Observations on 05/29/2023 between 11:30 AM and 1:00 PM of kitchen revealed the following: -Cook F failed to clean the counter in between purees of different foods. [NAME] F pureed meat, 455961 Page 11 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0812 Level of Harm - Minimal harm or potential for actual harm changed gloves, then pureed vegetables. [NAME] F left the food soiled disposable gloves on the counter and failed to discard them in trash the can, while pureeing food. -DS H, [NAME] F and [NAME] G entered and exited the kitchen numerous times without changing gloves or performing hand hygiene during meal service. They handled resident food trays and plated food items. Residents Affected - Some -Staff did not put soiled disposable gloves in the trash can, soiled gloves were thrown on the floor next to trash can. During an interview on 05/29/2023 at 10:30 AM, [NAME] G stated food items should have been dated when they arrived in the kitchen, when they were opened, and with a use by date. [NAME] G stated food items should have been discarded after 7 days. [NAME] G stated the big containers contained thickener, sugar and flour. [NAME] G stated there was a label on the containers the other day and didn't know why someone would have taken them off. [NAME] G stated she was the dietary manager but was now a cook. During an interview on 5/29/2023 at 1:10 PM, the DM stated she started in the position last week and was working under the Corporate Dietary Managers. The DM stated food items should have been dated with a receive date, open date and a use by date. The DM stated items should have been thrown out after 7 days. The DM stated the counter should have been cleaned between different types of puree food and dirty gloves should not have been left on the counter. The DM stated soiled gloves should have been thrown in the trash cans. The DM stated residents could have been affected by becoming sick because of cross contamination or food born illness. The DM stated what led to failure was lack of education. During an interview on 05/31/2023 at 11:44 AM, DS H stated she should have washed her hands every time she entered the kitchen and changed her gloves. DS H stated it was a crazy day and she just forgot to change her gloves and wash her hands. During an interview on 05/31/2023 at 4:45 PM, the ADMN stated her expectation was that food items in kitchen should have been labeled correctly with an open date, use by date and item description. The ADMN stated items should have been discarded after the use by date. The ADMN stated what led to the failure was the kitchen was in the middle of transition and there were some staff that where not happy with the transition. The ADMN stated the effect on residents could have been residents did not receive appropriate nutrition and food borne illness. Record review of CMS form 672, dated 5/29/2023, revealed 68 of 69 resident ate from the kitchen. Record review of the facility policy titled, Food and Safety and Sanitation Plan dated 11/28/2017, revealed: Review of Ready-to-eat food will be clearly labeled using calendar date to indicate the date the product was prepared and the date the product must be used or discarded. Use the following to determine the use by date: Held at 41°F or below= 7 days. Certain Bulk ready-to-eat foods (i.e. bulk cottage cheese, gallon milk, bulk sour cream) may go by manufacturer's use by date and do not need an additional use by date once opened . Commercially prepared PHF/TCS food products are clearly labeled using calendar date to indicate the date the product was opened and the date by which product must be used or discarded. The use by' date must not exceed the use by'' date established by the manufacturer . Thorough hand washing is required (but not limited to) the following situations: A. starting the work shift, B. after using the rest room, C. after handling raw food products, D. after 455961 Page 12 of 13 455961 05/31/2023 Palo Pinto Nursing Center 200 Southwest 25th Ave Mineral Wells, TX 76067

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coughing, sneezing, or touching hair or face, E. after eating, drinking or smoking, F. after use of any chemicals or cleaners. Record review of the facility policy titled Dry Food and Supplies Storage, dated 11/15/2017, revealed: 6. The practice of First In, First Out (FIFO) will be utilized. Products which do not have an imprinted use by or expiration date on the product, will be dated when received and rotated as new inventory is purchased (the oldest product will be moved to the front for use first). Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded. If product is delivered with and out of date expiration date the vendor will be called, the product will be removed from useable stock. 7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lids. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food . 9.All opened products must be resealed effectively and properly labeled, dated and rotated for use. This may require storage in an approved NSF container or food grade storage bag. 10. Use by, Best by and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Record review of the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/07/2023), Food Employees shall clean their hands and exposed portions of their arms . immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use article sp and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; .(D) . after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking . (E) After handling soiled equipment or utensils . (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. 455961 Page 13 of 13