Health inspection·November 10, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 observations, interviews, and record review the facility failed to ensure medications were stored in locked compartments to be accessed only by authorized personnel, and ensure medications were labeled in accordance with currently accepted professional principles, to include the appropriate accessory and cautionary instructions, and the expiration date in that: 148 residents medications were not properly labeled -Medications from pharmacy were not labeled with directions or expiration date. -Medication cart was left unlocked and unsupervised. This failure could place all 148 residents receiving medications in the facility at risk of unauthorized access to medication and medication administration error in administration which could lead to adverse reaction, potential harm. Findings Included: In a med pass observation on 11/8/22 at 8:12AM of the 2nd floor med cart revealed, medication packages from pharmacy. Packages for scheduled medications for all residents on this floor contained labels that did not contain expiration date of medication, the route of which medication was to be taken, and the directions on how often medication was to be taken. In an observation on 11/10/22 at 8:15AM revealed LVN C was walking out of resident room with insulin pen back to medication cart that was unlocked. She put the insulin pen back in the medication cart, left cart unlocked, and went back into the room to get hand sanitizer. In an observation on 11/10/22 at 8:27AM of the 4th floor med cart revealed, medication packages from Pharmacy. Packages for scheduled medications for all residents on this floor contained labels that did not contain expiration date of medication, the route of which medication was to be taken, and the directions on how often medication was to be taken. In an observation on 11/10/22 at 8:35AM of the 3rd floor med cart revealed, medication packages from Pharmacy. Packages for scheduled medications for all residents on this floor contained labels that did not contain expiration date of medication, the route of which medication was to be taken, and the directions on how often medication was to be taken. In an interview on 11/9/22 at 8:12AM with LVN H, she said she worked all floors in the facility Page 1 of 7 455983 455983 11/10/2022 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0761 Level of Harm - Minimal harm or potential for actual harm passing medications and all medications in the building were labeled the same way. She said she was trained to verify labels against the medication administration record and a medication error could occur because the label did not include the directions of how a medication should be given or the expiration date. She said she had not told anyone about the label being incorrect because all medications were labeled the same way. Residents Affected - Many In a phone interview with on 11/09/22 at 1:47PM with PHARMG , he stated a medication label legally must include: Patient name, facility name & address, physician name, pharmacy name & address, medication name, medication strength, medication directions, medication expiration date, date medication was filled. In a phone interview with on 11/09/22 at 1:55PM with PHARMF he stated a medication label legally must include: Patient name, facility name & address, physician name, pharmacy name & address, medication name, medication strength, medication directions, medication expiration date, date medication was filled. He said a prescription not labeled properly could potentially be dangerous to a patient. He said it was difficult to say what could happen as it would depend on the medication and issue. He said some medications could be dangerous if given the incorrect route because of absorption differences depending on route. In a phone interview with on 11/09/22 at 2:18PM with Pharmacist Consultant PHARME and Pharmacist and [NAME] President of Clinical Services PHARMD Consultant , they stated a medication label legally must include: Patient name, facility name & address, physician name, pharmacy name & address, medication name, medication strength, medication directions, medication expiration date, date medication was filled. PHARMD said a physician order, mar, and medication label should all match and be checked when passing medications. If these 3 things did not match there could be an increased risk for a medication error. In an interview on 11/10/22 at 8:15AM with LVN C, she stated she didn't lock the medication cart because she had to wash her hands and she didn't have hand sanitizer on the medication cart. She said it really was not a good excuse because she knew it was supposed to be locked and it could be dangerous if a resident were to take medication that was not prescribed to them. In an interview on 11/10/22 at 8:27AM with MA B said she works on all floors in the facility and all medications in the building were labeled the same way. She said she was trained to verify labels against the medication administration record and when the pharmacy started this new system a couple of years ago, she was nervous she was going to make a medication error because the label did not include the directions of how a medication should be given or the expiration date. She said since the prescription label did not have directions, she followed the medication administration record and assumed the pharmacy was correct. She said she had not told anyone about the label being incorrect because all medications were labeled the same way. In an interview on 11/10/22 at 8:35AM with LVN A said she passed medication for the entire third floor. She said she did not trust the prescription label to be correct since the directions were not written for each medication. She said she checks everything herself because she had found errors from the pharmacy in the past. She said the bag with the medication label on it was there to tell her what medications were supposed to be in the bag. She said prescription labels were supposed to have the directions and expiration date listed. She said she had been trained to check label against medication administration record and without the directions it could put a resident at an increased risk of medication error. 455983 Page 2 of 7 455983 11/10/2022 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In an interview on 11/10/22 at 1:28PM with the DON, he stated the people passing medications were trained to do a 3-check system comparing the prescription label to the medication administration record. He said the prescription label should include the route a medication should be taken, how often medication was to be taken, and the expiration date. He said he was not aware the medications labels throughout the building did not list these items. He said the pharmacy consultant company that comes in should have caught this error. He said there was a potential for a medication error to occur without these specific directions. He said they had been using for 2 years and had no complaints from staff about the labels being without needed information. He said if a nurse saw a prescription was not labeled correctly the pharmacy should be notified. He said this error was a concern for the entire facility because all of them could be at risk for a medication error despite an error not being made at this time. He said he was going to have pharmacy make this correction and it would be fixed by Saturday since all medications were delivered 2 days early. In an interview on 11/10/22 at 1:42PM with the ADM, she said she would not know how to give a medication based on the prescription label. She said the medication administration record should be used when passing medications. The DON explained to her the 3-step process of verifying medications were correct. She said in that case she understood this was a concern and could lead to a medication error. She said she would be placing phone calls to her corporate and the pharmacy to get labels corrected immediately. Record review of the email from to DON dated 11/10/22 stated the medication label at a minimum includes the medication name, prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration. Record review of the policy Administering Medications dated 12/2021 revealed the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the policy Labeling of Medication Containers dated 08/2021 revealed E. labels for each single unit dose package shall include all necessary information, such as: 5. The expiration date when applicable and 9. Directions for use. 455983 Page 3 of 7 455983 11/10/2022 St. Catherine Center 300 West Highway 6 Waco, TX 76712

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 observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for one of four kitchens reviewed for kitchen sanitation. A. The facility failed to properly store, label and cover food in the facility's walk-in refrigerator in the kitchen on 11/08/2022 from 8:30 AM -10:00 AM. B. The facility failed to ensure Dietary [NAME] I properly sanitized hands when placing food in bowls. C. Dietary [NAME] J failed to wear hair net when entering the main kitchen on first floor and Sous Chef K failed to wear a beard net when preparing food on the prep table in the main kitchen. These failures could place the residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings Included: A. Observation on 11/08/2022 from 8:30 AM -9:15 AM of walk-in refrigerator in the main kitchen on the first floor revealed the following: -slightly hardened left-over hoagie rolls not in the original bag was not labeled or dated. - leftover hamburger patties not in the original package that was not labeled or dated. - leftover fired mushrooms not labeled or dated. - bowls of shredded lettuce, prepared tuna salad, green bean salad, cheese, olives and orzo salad not labeled or dated. - container of strawberries with mold on approximately 6 strawberries not labeled or dated. - clear bag of shredded cabbage not in its original package with brownish color on the edges and in middle of the cabbage not labeled or dated. - two bags of shredded lettuce not in the original package had brownish color on the edges of the lettuce and some of the lettuce had brownish color on the entire lettuce not labeled or dated. - five half and half milk with best buy date of 10/22/22. - 13 tubes of hamburger meat on a silver tray not labeled or dated and not in the original container/box on the meal tray rack (approximately 8 -10 pounds each tube). B. Observation on 11/08/2022 at 9:00 AM reflected Dietary [NAME] I was placing bowls on the prep table. Dietary [NAME] I began to place red pureed beets into the bowls. She reached under the prep table and in a bucket of bubble liquid she grabbed a towel and began to wipe area of the prep table and 455983 Page 4 of 7 455983 11/10/2022 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many returned the towel into the bucket. Dietary [NAME] I did not remove her gloves after touching the wet towel with yellowish/ brownish stains on the towel. She continued with the task of placing red pureed beets into the bowls with the same gloves on her hands and 3 of her fingers on the right hand touched inside of the bowls (middle finger, index finger and ring finger). In an interview on 11/08/2022 at 9:10 AM Dietary [NAME] I stated she was placing pureed beets into the bowls. She stated she did touch the towel that was in disinfectant water under the prep table. She stated she did not remember if she changed her gloves or sanitized her hands. She stated she had been in serviced on removing gloves in between tasks and to wash hands prior to placing new gloves on her hands. She stated if she did not change gloves and wore the same gloves, she touched the towel it was a possibility she could contaminate the beets and inside the bowls with whatever was on the towel, and it was possibly disinfectant. Dietary [NAME] I stated she didn't change her gloves after touching the towel. C. Observation on 11/09/2022 at 8:05 AM Dietary [NAME] I walked in the first-floor kitchen without wearing a hair net. Observation of a sign posted on the door the Dietary [NAME] I entered revealed Hairnets need to be worn past this point. In an interview on 11/09/2022 at 8:20 AM Dietary [NAME] I stated she was in a hurry and forgot to place hairnet over her hair. She stated all hair nets are to be worn when entering any part of the kitchen area. She stated she had been in serviced on wearing hair nets prior to entering the kitchen area. She stated she knew the sign was on the door as a reminder to wear a hair net. She stated if staff did not wear hair nets hair could fall into food, plates, or on anything in the kitchen. She stated if hair was on the food a resident could eat the hair and possibly could become sick. Observation on 11/09/2022 at 8:10 AM Sous Chef K failed to wear a beard net when near food on the prep table and oven. His beard was approximately 8 inches long. In an interview on 11/09/2022 at 8: 35 AM Sous Chef K stated he forgot to placed beard net over his beard. He stated he had been in serviced on wearing beard nets when in the kitchen. He stated he was checking the food on the oven and the prep table. He also stated it was possible for hair from his beard to fall into the food or anything in the kitchen. He stated hair could contaminate the food and possibly cause illness to residents. In an interview on 11/10/2022 at 7:36 AM Executive Chef L stated all foods whether left-over foods or foods wasn't in the original container was expected to be labeled and dated. The left-over foods were especially needed to be labeled and dated. If the food had passed the use by date, it was expected to be disposed of in the garbage. All foods prepped to be used was expected to be labeled and dated. If any food had mold on it or was turning brown was to be thrown in the garbage. There should be no food in the refrigerator with mold or had turned brown. Any food or drinks with use by date in October 2022 required to be discarded in the garbage or sent back to the company responsible for delivering the milk. She stated if food or drinks was served after the use by date it was possible a resident could get food poisoning. She stated Dietary [NAME] I was to change her gloves after she touched the wet towel from the disinfectant water before continuing her task of placing pureed beets in bowls. She stated not changing gloves or sanitizing hands had a potential of contaminating the food with whatever was on the towel that touched her gloves. She stated all staff had been in serviced on hand hygiene. She stated no matter where staff is in the kitchen area once you enter the double 455983 Page 5 of 7 455983 11/10/2022 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm doors all staff was expected to place a hair net and beard net over their hair. She stated there were beard nets and hair nets beside all doors that enter the kitchen. She stated the hair nets was available for Dietary [NAME] I to place on her hair prior to entering the kitchen area. She stated the sign on the door was a reminder for all staff to wear hair net prior to entering any part of the kitchen. She stated Sous Chef K was expected to wear a beard net and all the males with facial hair had been in serviced on wearing beard nets. Residents Affected - Many In an interview on 11/10/2022 at 8:13 AM ADFS M stated all foods that was past the used by date was expected to be discarded end of shift of the used by date. If it was not discarded an employee possibly pick could up the food and use it for a meal or give it to a resident as a snack without looking at the use by date and the resident had a potential of getting food poisoning. The half and half milk that was out of date was to be sent back to the company or discarded. There should have been a sign on the crate the milk was in stating not to be used. All foods are to be labeled and dated. If staff not wearing hair nets, beard guards or not changing gloves after touching an item that was possibly contaminated, was not sanitary and could cause illness with the residents. Hair is considered contaminated if it is in a resident's food or on their plates. She stated all staff was expected to wear hair nets prior to entering any section of the kitchen and to always wear beard nets when in the kitchen. In an interview on 11/10/2022 at 8:30 AM SDFS N stated all foods are to be labeled and dated including leftover foods. Foods should be discarded the day after the use by date or at the end of shift of the used by date. Staff was expected to change gloves when touching anything in the kitchen that was considered contaminated including wet towel. The chemical from the towel had potential of being on the staff gloves and could possibly contaminate the food. He stated any food with mold should be discarded. All staff was expected to wear hair nets and beard nets prior to entering any door leading into the kitchen area. The main kitchen on the first floor is large and there were several doors entering the kitchen areas. He stated there were hair nets and beard nets beside each door. He stated the door Dietary [NAME] I entered there was a sign on the door not to enter unless wearing hair net. He stated hair from beard and from any part of the head could fall into resident's food or dinnerware. He stated a resident could possibly become sick if served out of date food, contaminated food from staff not changing their gloves and/ or from hair falling into their food. He stated it was his responsibility and the ADFS responsibility of monitoring to ensure all staff was following guidelines. In an interview on 11/10/2022 at 12:14 PM the Administrator stated all foods especially left-over food was expected to be labeled and dated. She stated the half and half outdated milk, molded strawberries, lettuce and cabbage with brown color were to be discarded. She stated all staff was expected to always wear hair nets and beard nets prior to entering any section of the kitchen. She stated hair can fall into the food and cause contamination. Facility Policy on Food and Supply Storage reflected foods past the use by, sell by, best by or enjoy by date should be discarded. Products are good through the close of the business on the dated noted on the label. Gloves are changed between tasks and hands are washed after gloves are removed. Facility Policy on Labeling and Record Keeping dated 10/1/2022 reflected all foods opened, prepared and used in the unit must be dated and labeled. Date marks are important for all TCS foods because while growth of bacteria in refrigerated foods is largely controlled by temperature, it is not stopped altogether. Date marks indicate when foods have been in refrigeration too long and have reached unsafe levels of bacterial growth. Common name labeling is also important since certain foods can be 455983 Page 6 of 7 455983 11/10/2022 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm difficulty to identify once they are processed or removed from their original package. Date all foods when they are prepared or when the original package is opened. Sandwiches, salads, yogurt and cut fruit salads must be marked with an easily identifiable date marking system. All foods, including prepared items, bulk foods, frozen foods and ingredients must be always labeled. Labeled with the common name, preparation date, discard date and associate initials. Residents Affected - Many 455983 Page 7 of 7