Health inspection·July 28, 2022

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 re-evaluate the use of an as needed (PRN) psychoactive drug, for one resident (Resident #25) of seven residents reviewed for unnecessary medications, in that: The facility administered a psychoactive medication (Lorazepam) PRN (as needed) to Resident #25, for more than 14 days, without an evaluation by Resident #25's physician for the appropriateness of the medication. This failure could place all residents on psychoactive medications at risk for receiving unnecessary drugs. The findings included: Record review of Resident #25's May 2022 face sheet revealed Resident #25 was [AGE] year-old female admitted to the facility on [DATE]. Resident #25's diagnoses included respiratory failure, liver disease, anxiety, and schizoaffective disorder (a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms such as depression or mania). Record review of Resident #25's Minimum Data Set revealed the resident had a BIMS score of 10 of 15 indicating moderate cognitive decline. Record review of Resident #25's Care Plan dated 07/07/2022 indicated Problem: Psychotropic drug use; Resident receives antianxiety medications related to diagnosis of anxiety disorder. Intervention for this problem was Monitor for drug use effectiveness and adverse consequences. Record review of Resident #25's physician orders dated 05/21/2022 included lorazepam (Ativan) 0.5 mg by mouth three times a day as needed for anxiety. Record review of Resident #25's Medication Administration Record for June 2022 revealed Resident #25 received: - one dose of lorazepam (Ativan) 0.5 mg on 15 of 30 days and - two doses of lorazepam (Ativan) 0.5 mg on 19 of 30 days. Record review of Resident #25's Medication Administration Record for July 2022 revealed Resident Page 1 of 6 675009 675009 07/28/2022 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0758 #25 received: Level of Harm - Minimal harm or potential for actual harm - one dose of lorazepam 0.5 mg on 5 of 28 days and - two doses of lorazepam 0.5 mg on 1 of 28 days in July 2022. Residents Affected - Few Record review of Resident #25's progress notes dated 6/2/22, 6/9/22, 6/16/22, 6/24/22, 7/1/22, 7/7/22, 7/15/22, 7/21/22, and 7/28/22 revealed a psychiatric nurse practitioner assessed the resident following the order for lorazepam (Ativan) 0.5 mg. The psychiatric nurse practitioner notes indicated visits were due to psychiatric follow up and no medication change was needed. Record review of Resident #25's primary care provider notes of routine visits dated 6/10/22 and 7/14/22, indicated no new orders. Record review of Resident #25's consent forms revealed the Use of Psychoactive Medication Therapy form was not in the electronic medical record. During an interview on 07/28/22 at 1:30 p.m. LVN A reviewed Resident #25's MAR for May, June, and July 2022 and stated lorazepam was ordered for Resident #25 as needed beyond a 14-day limit. LVN A stated she was not aware a physician's review was required after 14 days for psychoactive medications ordered as needed. LVN A stated Resident #25 started refusing medications on 7/13/22. During an interview on 07/29/22 at 11:40 a.m., the DON stated the failure occurred because she should have reminded the physician to review the medication 14-days after it was prescribed. She was not able to explain how the facility monitors as needed psychoactive medication orders to ensure a review was done after 14 days. The DON stated the resident did not suffer any adverse effects due to receiving the medication beyond the 14-day guideline. Record review of the facility's policy, Administering Medications dated April 2019 stated, If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. Record review of the facility's policy, Medication Monitoring Medication Management dated 2007 stated PRN orders for psychotropic medications, excluding antipsychotics, Time Limitation 14 days; Exception Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Required Actions Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. 675009 Page 2 of 6 675009 07/28/2022 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility failed to follow menus for 2 of 2 pureed recipes observed for meal accuracy. Residents Affected - Few The facility failed to ensure pureed recipes were prepared as directed while preparing pureed fish when the Dietary [NAME] A added thickener to the already prepared fish on the steam table. The facility failed to ensure pureed recipes were prepared as directed while preparing pureed meatballs when the Dietary [NAME] A did not measure any ingredients when preparing pureed meatballs. These failures could place residents at risk for dissatisfaction, poor intake, altered nutritional status, choking, and/or weight loss. The findings included: During observation of steamtable on 07/26/22 11:45 AM, [NAME] A picked up a plastic container labeled thickener and added 2 tablespoons of powdered thickener to the pureed fish in a small pan already on the steam table and stirred it. During on observation of pureed preparation on 07/27/2022 at 11:45 PM, [NAME] A placed 6 meat balls in the blender. She had 2 cups of what she stated to be beef broth already prepared in a cup and placed 4 scoops of power from a plastic container labeled as thickener into the cup. She poured ½ cup of the thickened broth into the blender and blender for approximately 1 minute. The Dietary Manager was in the kitchen and observed [NAME] A perform the task. [NAME] A did not have the recipe out while performing task. During an interview on 07/27/2022 at 12:00 PM, [NAME] A stated she did not use the recipe because she just judged it by looking at the thickness. She stated she should use the recipe when preparing pureed meals to ensure residents receive the proper proportions and nutritional value. She stated the pureed fish had gotten too thin while sitting on the steam table on 7/26/22, which was why she added more thickener. She stated she should have thrown out the thin pureed fish and prepared new pureed fish instead of adding the thickener. During an interview on 07/27/2022 at 12:10 PM, the Dietary Manager stated staff should always use a menu. She stated there were 2 residents with pureed diets. The Dietary Manager was unable to locate the recipe. She stated failing to follow the recipe could result in too small or too large portion sizes. During an interview on 07/27/2022 at 12:15 PM, the Dietician stated dietary staff should have followed the recipes for all foods and especially pureed foods. She stated this could affect the residents by not getting the proper nutrition leading to weight loss and other issues. During an interview on 07/27/2022 at 1:30 PM, the Administrator stated she was a new administrator and did not know much about the kitchen. She stated following recipes was very important to ensure residents receive the proper proportions and nutritional value. The administrator was unable to provide the pureed recipes. 675009 Page 3 of 6 675009 07/28/2022 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's dietary contract company policy, Food: Quality and Palatability, original date October 2019 revealed: Policy Statement: It is the center policy that, food is prepared by methods that conserve nutritive value, flavor, and appearance. Food is palatable, attractive, and served at a safe and appetizing temperature. Action Steps: 1.) The Dinning Services Director and Cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines and standardized recipes. 675009 Page 4 of 6 675009 07/28/2022 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

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 food was not kept in the refrigerator longer than 7 days or past the expiration date. The facility failed to adequately sanitize the food temperature testing device prior to, in between, and after taking temperatures of foods. The facility failed to ensure proper sanitation and food handling by not performing hand hygiene and changing gloves when contaminated. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings include: During an observation of the kitchen on 07/26/22 at 10:30 AM, observed: 1.) 5 clear plastic zipped storage bags in a container in the refrigerator labeled chicken breast prepped 07/18/2022. 2.) Clear plastic zipped storage bags labeled honey smoked ham 06/02/2022 3.) Clear plastic zipped storage bags labeled honey smoked ham 07/12/2022. During an observation of meal service on 07/26/22 at 11:45 AM, [NAME] A donned gloves without washing her hands. [NAME] A wiped food temperature testing device with a wet blue food service towel that she picked up off the counter. [NAME] A placed food temperature testing device into a fried fish patty. Temperature read 178 degrees. [NAME] A then wiped food temperature testing device with the same wet towel she had in her hand. [NAME] A placed food temperature testing device inside a french fry. Temperature read 169 degrees. [NAME] A wiped food temperature testing device with same wet towel and placed food temperature testing device into the cabbage. Temperature read 35 degrees. [NAME] A dropped the towel on the floor, picked up the towel, and threw it in the trash can. [NAME] A did not change gloves, grabbed a dry food service towel, wiped food temperature testing device, and placed towel on the counter. [NAME] A placed food temperature testing device inside steam cabbage. Temperature read 186 degrees. [NAME] A picked up same dry towel from counter and wiped the food temperature testing device. [NAME] A placed the food temperature testing device into the pureed fish. Temperature read 192 degrees. [NAME] A wiped the food temperature testing device with same dry towel and placed food temperature testing device into mashed potatoes. Temperature read 197 degrees. [NAME] A removed 675009 Page 5 of 6 675009 07/28/2022 Coleman Healthcare Center 2713 S Commercial Ave Coleman, TX 76834

F 0812 gloves and washed her hands. Level of Harm - Minimal harm or potential for actual harm During an observation of meal service on 07/26/22 11:45 AM performed by [NAME] A and Dietary Aide. Dietary Aide opened kitchen door, went to ice machine, and got ice out without gloves. Dietary Aide opened kitchen door to reenter and donned gloves without washing her hands. [NAME] A applied gloves without handwashing or sanitizing. [NAME] A then placed 3 serving trays on the steam table touching the top of the pans with pureed food in them on the steam table, she then placed 3 plates on the trays and touched each plate on top with her hands. Dietary aide applied gloves without handwashing or sanitizing. Dietary Aide went to the refrigerator, opened the door with gloves hands, and then went back to the serving table. Dietary Aide touched a piece of bread and placed in onto a resident's plate. Dietary Aide then grabbed a brownie in a plastic bag and placed it on the residents serving tray. Dietary Aide repeated this multiple times. Dietary Aide opened the kitchen door and pushed a cart full of trays into the dining room, reentered the kitchen, and grabbed a piece of bread and placed onto a resident's plate with no change of gloves. [NAME] A went to the refrigerator with same gloves on from serving and removed a plastic bag with cheese in it. [NAME] A touched the cheese and placed in onto a piece of bread, placed another piece of bread on top, and laid in on a plate. She placed butter in a frying pan and placed bread and cheese in the pan. [NAME] finished cooking sandwich and placed on a plate and handed to another staff for a resident. Residents Affected - Many During an interview on 07/26/2022 at 1:00 PM, Dietary [NAME] A stated she had been working in the facility for 2 months. She stated she had her food handler's certification. She stated she should wash her hands after removing gloves and before applying new gloves. She stated touching things contaminates gloves and the gloves should be changed. She stated she should never touch an appliance and then handle food with the same gloves. She stated she did not have any alcohol wipes to sanitize the food temperature testing device, so she used a sanitized towel. She stated she should have placed the dry towel in the sanitation bucket before using it to wipe the temperature testing device. During an interview on 07/27/2022 at 09:45 AM, the Dietary Manager stated foods should be discarded after 7 days of opened date. She stated the dates on all the food were the open dates. She stated frozen food should only be thawed for a maximum of three days. She stated the temperature testing device should always be cleaned with alcohol and wiping it with a try towel in between temping foods was unacceptable. She stated she had been a dietary manger for 5 months and she has her dietary manager certification. During an interview on 07/27/2022 at 1:30 PM, Administrator stated she was a new administrator and did not know much about the kitchen. Administrator stated proper hand hygiene and sanitation was very important in the kitchen. Review of the facility's dietary contract company policy, Food Preparation, original dated October 2019 revealed: Policy Statement: It is the center policy that all foods are prepared in accordance with the guidelines of the FDA Food Code. Action Steps: 1.) The Dinning Services Director ensure that all staff practice proper hand washing technique and practice proper glove use. 2.) The Dinning Services Director or Cooks are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 3.) The Dinning Services Director or Cooks are responsible to ensure that all utensils, food contact equipment, and food contact surfaces are cleaned and sanitized after every use .15.) All Time/temperature Control for Safety foods that are to be held for more than 24 hours at the temperature of 41 degrees or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). 675009 Page 6 of 6