Health inspection·September 7, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 16 residents (Resident #6) reviewed for resident rights. The facility failed to treat Resident #6 with respect and dignity when she had to ask staff where her food was three times while the other residents seated with her in the dining room were already eating. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings: Record review of facility face sheet dated 09/06/2023 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of cerebral infarction (stroke). Record review of quarterly MDS dated [DATE] revealed a BIMS of 12 indicating moderate cognitive impairment and required supervision and setup with eating. During an observation on 09/05/23 at 12:33 pm revealed two residents were seated at the table with Resident #6 for the noon meal. The other two residents were served their meal while Resident #6 was not. Resident #6 asked facility staff three times where her food was. After the third time asking, CNA L got Resident #6's food from the kitchen. During an interview on 9/5/23 at 12:45 pm Resident #6 stated she wanted to eat and everyone else had their food but her. She stated she did not know why her food was not served with the other residents. During an interview on 9/5/23 at 12:52 pm CNA L stated that she had worked at the facility for several years and was responsible on her shift to pass meals to the residents. She stated that prior to each meal the meal tray cards were reviewed and put in order for the dietary staff to know who was present in the dining room and who was sitting with who. She stated the cards were given to the cook and the cook then prepared the plates for them to pass out. She stated she did not realize Resident #6 was not served until she heard her talking about wanting her food. She stated by not serving each resident at the table at the same time could be humiliating and make them upset if they are not getting to eat like the others. Page 1 of 21 675358 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/5/23 at 3:51 pm the cook stated that she organized the tray cards most days or the CNA's would if she was unable to. She stated the CNA's put them in order today and she was not aware Resident #6 had not gotten her tray when the others at the table were served until a CNA told her. She stated it was not right for a resident to sit and watch someone else eat and ask for their food. She stated she would make sure from now on that the meal cards were in order to ensure a resident does not have to be humiliated. During an interview on 09/07/23 at 09:02 am LVN K stated the nurse was responsible for checking the resident orders against the meal tray card and that the correct diet was given as well as monitoring the dining room. She stated each table should be served together so the residents do not think they were not getting fed. She stated if she observed a resident has not been served, she would notify the kitchen and get their food. She stated if a resident were not served with other residents at the table, it could cause them anxiety or embarrassment. During an interview on 09/07/23 at 09:18 am the DON stated she was responsible for ensuring nursing staff knew how to maintain resident dignity. She stated staff have been trained on dignity and resident rights on hire, annually and as needed. She stated the CNA's were responsible for ensuring each resident at each table were served at the same time. She stated if a resident were not served their meal with the other residents, they could feel secluded and left out. She stated she expected for all staff to maintain resident's rights and dignity and would improve on communication with the nursing and dietary staff when delivering meals. During an interview on 09/07/23 at10:08 am the administrator stated a manager on duty was typically assigned to the dining room to prevent this mistake from happening and he provided training to staff on providing dignified care to each resident. He stated he expected all residents to be treated with respect and dignity in order to prevent a resident psychosocial wellbeing being affected. Record review of facility policy titled Resident Rights dated August 14, 2022, indicated, the staff will abide by and protect resident rights in accordance with state and federal guidelines . Record review of facility policy titled Meal Service and Distribution dated August 1, 2018, indicated, dining your way is an enhanced mealtime experience for all residents, emphasizing choice, dignity and customer service . 675358 Page 2 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #43) reviewed for notification of changes in that: The facility did not notify Resident #43's physician (Physician M) for a significant change in weekly weight indicating a gain of 5-pound gain or greater as ordered (weight gain of 59.1 pounds.) This deficient practice could place residents at risk of not having their physician notified of changes resulting in a delay in continuity of care. The findings were: Record review of Resident #43's face sheet, dated 09/06/23, revealed Resident #43 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic lung disease), coronary artery disease (blockage of the coronary arteries), anxiety (feeling anxious) and hypertension (high blood pressure). Further record review of this document revealed Resident #43 did not have a responsible party or a guardian. Further record review of this document revealed Resident #43's primary physician was Physician M. Record review of Resident #43's entry MDS, dated [DATE], revealed Resident #43 had a BIMS score of 15, signifying he was cognitively intact. Record review of this same document, revealed the following item: - Section G, Item G0110. Activities of Daily Living (ADL) Assistance. Review of this item revealed Resident #1 required one-person physical assist with the following activities of daily living: bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #43's orders dated 9/06/23, indicated: weekly weights every Wednesday on Day Shift- weight weekly, notify MD if weight gain or loss of 7 lbs. Weight Check- notify MD if weight varies 7lbs in one week * MD Call Dx: Chronic obstructive pulmonary disease with (acute) exacerbation. Record Review of the weights tab in the electronic medical record indicated: 08/02/23 weight 315.8 08/07/23 weight 315.8 08/09/23 weight 315.8 08/18/23 weight 316.5 08/23/23 weight none 675358 Page 3 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0580 08/30/23 weight 375.6 Gain of 59.1 pounds Level of Harm - Minimal harm or potential for actual harm 09/06/23 weight 376.4 Residents Affected - Few Record review of Resident #43's care plan, dated 09/06/23, revealed the following Focus area initiated on 8/2/23: Edema- Daily weights as ordered Notify MD of weight over 2 pounds in one day. Record review of Resident #43's Nurses Notes, dated 08/02/23 thru 9/06/23 revealed no documentation indicating Physician M, was notified of any weight gain as ordered Record review of Resident #1's Progress Notes from 08/02/23 to 09/06/23, revealed no progress note which indicated Physician M was notified of Resident #43 weight gain. During an interview on 09/06/23 at 4:00 PM with the ADON, DON and Regional Nurse verified there was no documentation in the medical records of notification of the 59.1-pound weight gain on 8/30/23. The DON stated that she weighed him on 08/30/23 in his wheelchair and reduced the total of the wheelchair. The DON said Resident #43 was weighed again 09/06/23 with the Hoyer lift scale Maximum capacity of 450 pounds and she completed an assessment of Resident #43 for signs of fluid overload. The ADON stated that the weights from 08/03/23 until 8/30/23 were inaccurate and put the residents at risk for fluid overload if accurate weights and reporting of ordered perimeters were not reported to MD. The DON said not getting and reporting weight gains as ordered put residents at risk for-fluid overload. She said the staff had recorded a stated weight from the resident and did not weigh him. The ADON said Resident #43 had a history of refusing his weekly weights, diuretics and other interventions. The DON said Resident #42 had a physician order to be weighed weekly and to report a gain of greater than 5 pounds. The DON said there was no documentation in the medical record that the MD had been notified of Resident #43 refusals to be weighed. The DON said she had witnessed Resident #43's refusal of weight on admission but failed to document the refusal. During an interview on 09/07/23 10:16 AM DON said that she had started in-service of all nursing staff to notify MD of resident changes and to follow orders for weekly weight and reporting requirements as ordered by MD. The DON said the resident had refused a weight on admission and had continued to refuse, the weekly weight had been recorded as the resident stated because there was no other actual weight until 08/30/23 when she and LVN J weighed him. She did not report the weight to the MD on 08/30/23 due to the electronic system was down and she had no access to the last weeks weight to compare. The DON said there was no weight book or other means of access to weights other than the electronic record. During an interview on 09/07/23 at 10:30 AM with LVN J said he was employed at the facility as an LVN since 01/23. LVN J said there was no designated staff member that weighed the residents. He said he had assisted the DON obtain weights for Resident #43 in his wheelchair on 8/30/23 and 09/06/23 using the Hoyer scales. LVN J said the weights were accurate as recorded in the medical record for those dates. During an interview on 09/07/23 at 11/15 a.m. the Administrator stated he did not know if Physician M was notified regarding Resident #1's weight gain. The Administrator stated, I expect nursing staff to always notify the physician of change in condition including orders to be notified of weight gains. Record Review of Policy for Change of Condition dated 02/23 indicated .1. Changes in Condition are 675358 Page 4 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0580 determined by current and past medical conditions, medical orders, patient safety factors and/or by assessments utilizing defined parameters .3. Sign and Symptoms .A Marked Change. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675358 Page 5 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #259) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #259 addressing oxygen use. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings: Record review of facility face sheet dated 9/06/2023 indicated Resident #259 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial flutter (irregular heartbeat), and chronic obstructive pulmonary disease (COPD) (impaired lung function). Record review of facility admission data report dated 08/20/2023 indicated Resident #259 was receiving continuous oxygen. Record review of admission MDS dated [DATE] indicated Resident #259 had a BIMS of 15 indicating intact cognition and required oxygen prior to admission and while a resident at the facility. Record review of comprehensive care plan dated 8/27/2023 indicated Resident #259 had COPD and required oxygen at home but did not indicate oxygen use at the facility. On 09/06/2023 the care plan was updated to include the need for continuous oxygen at 3 liters per nasal cannula. Record review of physician order dated 09/06/2023 indicated order for oxygen continuous at 3 liters per nasal cannula. During an observation on 09/05/23 at 11:38 am Resident # 259 was sitting up in her recliner. She had in place oxygen at 1.5 liters per nasal cannula. During an interview on 09/05/2023 at 11:40 am Resident # 259 stated she has required oxygen since her hospitalization and wears it all the time. During an observation on 09/06/23 at 1:30 pm Resident # 259 was sitting in her recliner with oxygen in place set at 1.5 liters per nasal cannula. During an observation on 09/06/2023 at 3:02 pm Resident # 259 was ambulating in the hallway behind a wheelchair and had oxygen on per portable oxygen tank at 1.5 liters per nasal cannula. During an interview on 09/06/23 at 01:55 pm LVN J stated he had worked at the facility for 9 months. He stated when a resident admitted to the facility, the nurse was responsible for entering all orders into the medical record including oxygen orders. He stated he was the admitting nurse for 675358 Page 6 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0656 Level of Harm - Minimal harm or potential for actual harm Resident #259 and had included the oxygen on his admission note but forgot to add the order. He stated Resident #259 was discharged from the hospital with oxygen and should have had an order for oxygen if they were using it and the care plan should also reflect that oxygen was ordered. He stated he did not complete the care plan and the RN was responsible for the care plan. He stated if the resident's orders and care plan were not accurate it could affect the resident's health. Residents Affected - Few During an interview on 09/06/23 at 01:59 pm LVN K stated she had worked at the facility for 1 1/2 years and the admitting nurse was responsible for ensuring all orders were entered in the medical record. She stated if a resident was receiving oxygen there should be an order for the oxygen and oxygen use should be on the care plan. She stated the RN was responsible for updating the care plans. She stated if the resident's orders or care plan were not accurate it could affect healthcare delivery or cause a delay in care. During an interview on 09/06/23 at 2:09 pm the MDS coordinator stated when a resident admitted to the facility, the nurse completed the admission data assessment and entered orders into the electronic health record. She stated from the admission data and orders the baseline care plan was generated and then she would manually adjust the interventions and goals for the comprehensive care plan. She stated Resident # 259 should have an order for oxygen and had been on oxygen since she was admitted . She stated she completed Resident # 259's admission MDS and completed oxygen section based on the nurses notes and observations and did not recognize there was not an order and the care plan had not been added for oxygen therapy. She stated she would correct the error to ensure accurate resident care. During an interview on 09/07/23 at 9:28 am the DON stated when a resident was admitted the nurse entered the orders and then the orders were reviewed in the morning meeting to ensure accuracy. She stated she missed that Resident #259 did not have an order for oxygen and her care plan did not reflect oxygen use. She stated when a resident used oxygen there should be an order for the oxygen and the care plan should reflect the need for oxygen as well. She stated care plan accuracy was the responsibility of the MDS coordinator and herself. She stated the comprehensive care plan should reflect all services the resident received. She stated if a resident's orders were not accurate care delivery could be affected and if the care plan was not accurate could cause potential for error. She stated she expected all nurses to accurately input all orders and for the care plan to reflect the resident's needs. During an interview on 09/07/23 at 10:05 am the administrator stated his role was to participate in the weekly meetings with nursing staff to discuss the new admissions. He stated the order entry and care plan accuracy was the responsibility of nursing administration. He stated the risk of not having accurate orders and care plan could cause potential care not being provided and individual care plan not being followed. Record review of facility policy titled Care Plan Process dated February 12, 2020, indicated, .coordinate an appropriate care plan for the resident's needs and wishes based on assessment. The care plan identifies the date, problem, and goals . 675358 Page 7 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #43) reviewed for care plans. The facility failed to ensure Resident #43's care plan was revised to reflected current orders for monitoring weekly weights and reporting greater than 5-pound weight gain. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of a face sheet for Resident #43 dated 6/20/23 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression, and hypertension. Record review of a quarterly MDS assessment dated [DATE] for Resident #43 indicated that he had a BIMS score of 15, indicating that he was cognitively intact. Record review of comprehensive care plan revision date 8/13/2023 indicated Resident #43 was taking a diuretic. The care plan was not revised to include the weekly order for weights and to report a weight gain of greater than 5 pounds to MD. Record review of physician order dated 09/06/2023 indicated order for oxygen continuous at 3 liters per nasal cannula. In an interview on 09/06/23 at 02:09 PM the MDS coordinator stated when a resident admits the resident admission data was completed by the admitting nurse and orders were entered into the system. From the admission data and orders the care plan was initially generated and then she manually adjusts the interventions and goals for the comprehensive care plan. She stated Resident #43 had an order for weekly weights on each Wednesday with reporting of gain of 5 pounds since he was admitted . She stated she completed Resident #43's admission MDS and failed to catch that the system had generated an intervention to weigh the resident daily and report a two-pound weight gain that had continued. The MDS Nurse stated she did not revise the care plan. She said she would correct it right away since the order had changed again on 09/06/23 for weekly weights and reporting a 7-pound gain in one week to ensure accurate resident care. In an interview on 09/07/23 at 09:28 AM the DON stated when a resident is admitted the nurse enters the orders and then the orders are reviewed in the morning meeting to ensure accuracy. When a resident has an order for weekly weights with reporting perimeters, the order should be reflected in the care plan. The care plan accuracy is responsibility of MDS nurse and DON. The MDS Nurse said the care plan starts on admission with the initial orders and assessments. The comprehensive care plan should reflect all services to the resident. If a resident's orders are not accurate care delivery could be affected and if the care plan is not accurate could cause potential for error. Expectation going forward is to in-service nurses on following the plan of care. 675358 Page 8 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/07/23 at 10:05 AM the Administrator stated his role is to participate in weekly meetings with nursing staff. The order and care plan accuracy are the responsibility of the nursing administration. The Risk to resident could be potential care not being provided and individual care plan not being followed. Review of facility policy titled Care Plan Process dated 2018 with revision date of March 2023 indicated .The comprehensive, person-centered care plan will: .based on the physician's orders and nursing evaluation. 675358 Page 9 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

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 ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 1 of 8 residents (Resident #259) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #259 had an order for oxygen therapy and the correct liter flow was administered to the resident. This failure could place residents requiring O2 therapy at risk of hypoxia and not receiving prescribed care and services. Findings: Record review of facility face sheet dated 9/06/2023 indicated Resident #259 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of atrial flutter (irregular heartbeat), and chronic obstructive pulmonary disease (COPD) (impaired lung function). Record review of facility admission data report dated 08/20/2023 indicated Resident #259 was receiving continuous oxygen. Record review of admission MDS dated [DATE] indicated Resident #259 had a BIMS of 15 indicating intact cognition and required oxygen prior to admission and while a resident at the facility. Record review of comprehensive care plan dated 8/27/2023 indicated Resident #259 had COPD and required oxygen at home but did not indicate oxygen use at the facility. On 09/06/2023 the care plan was updated to include need for continuous oxygen at 3 liters per nasal cannula. Record review physician order dated 9/06/2023 indicated Resident #259 required oxygen continuous at 3 liters per nasal cannula. During an observation on 09/05/23 at 11:38 am Resident # 259 was sitting up in her recliner. She had in place oxygen set at 1.5 liters per nasal cannula. During an interview on 09/05/2023 at 11:40 am Resident # 259 stated she has required oxygen since her hospitalization and wears it all the time. During an observation on 09/06/23 at 1:30 pm Resident # 259 was sitting in her recliner with oxygen in place set at 1.5 liters per nasal cannula. During an observation on 09/06/2023 at 3:02 pm revealed Resident # 259 was ambulating in the hallway behind a wheelchair and had oxygen on per portable oxygen tank at 1.5 liters per nasal cannula. During an interview on 09/06/23 at 01:55 pm LVN J stated he had worked at the facility for 9 months. He stated when a resident admits to the facility, the nurse was responsible for entering all orders into the medical record including oxygen orders. He stated he was the admitting nurse for Resident #259 and had included the oxygen on his admission note but forgot to add the order. He stated a 675358 Page 10 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident should have an order for oxygen if they were using it and the nurse should ensure the resident was receiving the correct flow of oxygen. He stated if the resident's orders and oxygen administration were not accurate it could affect the resident's health. During an interview on 09/06/23 at 01:59 pm LVN K stated she had worked at the facility for 1 1/2 years and the admitting nurse was responsible for ensuring all orders were entered in the medical record. She stated if a resident was receiving oxygen there should be an order for the oxygen and the nurse should check to make sure the resident was receiving the correct liter of oxygen per the order. She stated if the resident's orders were not accurate, and the resident was not receiving the correct liter of oxygen it could affect healthcare delivery. During an interview on 09/06/23 at 2:09 pm the MDS coordinator stated when a resident admitted to the facility, the nurse completed the admission data assessment and entered orders into the electronic health record. She stated Resident # 259 should have an order for oxygen and had been on oxygen since she was admitted from the hospital. During an interview on 09/07/23 at 9:28 am the DON stated when a resident was admitted the nurse entered the orders and then the orders were reviewed in the morning meeting to ensure accuracy. She stated she missed that Resident #259 did not have an order for oxygen. She stated when a resident used oxygen there should be an order for the oxygen. She stated if a resident's orders were not accurate care delivery could be affected. She stated she expected all nurses to accurately input all orders and ensure the resident was receiving the correct order. During an interview on 09/07/23 at 10:05 am the administrator stated his role was to participate in the weekly meetings with nursing staff to discuss the new admissions. He stated the order entry was the responsibility of nursing administration. He stated the risk of not having accurate orders could cause potential care not being provided. Record review of facility policy titled Applying an Oxygen Delivery Device dated January 12, 2020, indicated, .validate physician orders, verify setting on the oxygen source and the prescribed flow rate . Record review of facility policy titled Physician Orders-Electronic dated January 12, 2020, indicated, .the licensed nurse will receive and transcribe the physician's orders according to practice guidelines, provide treatments as ordered by the physician, and clarifies and reconciles all orders that may lead to an administration error . 675358 Page 11 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

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 provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication storage room reviewed for pharmacy services. The facility failed to properly date Tubersol Purified Protein Derivative (Mantoux Tuberculosis skin testing solution) in the medication storage refrigerator with an open date. The facility failed to remove 2 vials of Flucelvax from the medication storage room refrigerator that had expired on 06/30/2023. The facility failed to monitor and log the temperatures of the medication storage refrigerator twice daily as indicated by policy. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on 09/06/23 at 7:30 AM with LVN J the medication room refrigerator had 1 opened vial of Tubersol Purified Protein Derivative prescription date filled 6/23 with no open date and instructions to dispose of 30 days after opening and 2 vials of Flucelvax (influenza vaccine) with expiration date of June 30, 2023. During an observation and record review on 09/06/23 at 7:40 AM of medication refrigerator log posted on the medication room refrigerator for September 2023 indicated, instructions to check medication refrigerator and freezer at least twice each day and log temperatures for the refrigerator and freezer twice daily. Log indicated no temperature recorded for freezer AM 09/01/23, 09/02/23, 9/03/23 and only PM recorded 09/04/23 and 09/05/23. Log indicated no temperature recorded for refrigerator 09/01/23 PM, 09/02/23 AM none for 09/03/23, none for 09/04/23 and 09/05/23 PM. During an interview on 09/06/2023 at 7:45 am LVN J stated that Tuberculosis skin test and Influenza vaccines were usually by the given by the administrative nurses and it was each nurses responsibility to check the expiration date on all medicine before it was given. He stated multi-use vials were to be dated and they were usually only good for 30 days. He stated he had received training on multi use vials use by dates. He stated the risk could be ineffective medication. He stated the temperature of the refrigerator and freezer should be logged twice a day and recorded. During an interview on 09/06/2023 at 10:55 am the DON stated the nurses were responsible for monitoring the medication refrigerator, removing expired medications, and dating all multiuse vials when opened. She stated she had started in servicing on expired medications and logging the temperature of the refrigerator. She stated it was her responsibility to provide oversight, she had just cleaned out the refrigerator in the medication room but missed the 2 vials of flu vaccine and the Tubersol. She stated the risk could be ineffective medication. During an interview on 09/07/2023 at 11:15 am the administrator stated the DON and ADON were 675358 Page 12 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for medication storage and removing expired medications for destruction. He stated he was not sure how long multiuse vials were good for but if a resident were to receive expired medications it could not work or make them sick. Record review of a manufacturers insert for Tubersol indicated expiration dates indicated, Tubersol beyond use date, 30 days after opening. Record Review of policy for medication storage dated 2007 PharMerica Corp Indicated, . 11. Medications requiring refrigeration or temperatures between 36 degrees and 46 degrees with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that the temperature has remained within accepted limits. 14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists, . 675358 Page 13 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: Residents Affected - Many The facility failed to ensure opened items in the dry storage were labeled and dated correctly. The facility failed to ensure all food items were discarded by the expiration date. The facility failed to ensure there was soap at the handwashing sink. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: During an observation and interview on 9/5/23 beginning at 10:48 am it was observed that there was no soap at the handwashing sink. The DM said that she was not responsible for the soap, that it had been out about a day and that staff were washing hands in the dish sink using the hose that has hot water and soap mixed together. The ish sink observed with dirty dishes in it, there was a hose on the left side that had a button to push and hot water mixed with soap would come out of the hose while the button was pushed. The end of the hose was submerged in dirty dishwater. A large open bag of powdered sugar was observed on top of the milk cooler in the dry storage room. There was no open date, bag was open to air, not sealed in any type of container. A bag of Oreo medium cookie pieces was observed open on the dry storage rack with no open date, and not in a sealed container with an expiration date of June 8, 2023, noted. A large white box observed in dry storage area with a large clear plastic non-sealable bag containing a white, powdery substance was observed open to air, not closed or in a sealable container. Box was labeled food thickener and had an open date of 6/2/23. During an observation on 9/5/23 at 3:51 pm soap was now observed by the handwashing sink. The bag of powdered sugar remained open and on top of the milk cooler. Oreo cookie pieces were still open and on the dry storage rack, not sealed or labeled. Food thickener was still open on the storage rack. During an observation and interview with the [NAME] on 9/6/23 at 8:55 am, the sugar was observed still open and on the milk cooler. She said that it should not have been left out like that, but that it should be in some kind of sealed container with a label and date. She said that she had been trained by administration to label and date foods and keep opened foods in a sealable container. During an observation and interview on 9/6/23 at 9:00 am the DM said that she had been here almost 3 months and that residents eating expired or contaminated foods could be at risk for diarrhea, illness, or vomiting. Oreos still observed on shelf. Food thickener still observed open to air. During an interview with the DM on 9/7/23 at 9:00 am, she said that foods were checked for expired foods daily and was unsure how the Oreo's were missed. She removed the Oreo's immediately to discard. She said that any open foods should always be put in something that can be sealed once opened and dated with an open and a use by date. She said that the food thickener had just been opened this morning, but that she would get it taken care of. She said that there is a risk of illness to residents 675358 Page 14 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0812 if they consume contaminated foods. Level of Harm - Minimal harm or potential for actual harm During an interview with the Adm on 9/7/23 at 9:30 am he said that by staff not properly washing hands, or by residents consuming expired or contaminated foods, residents could get sick. He said that he expected the kitchen staff to properly label and store foods going forward and to let housekeeping know when the soap was out so they could get it replaced and properly wash their hands. He said he would be holding in-services with kitchen staff to reinforce trainings. Residents Affected - Many During an interview on 9/7/23 at 9:40 am the RD said that the food thickener should be sealed to prevent contamination by pests. She said that the dietary manager was new and still learning all of her responsibilities. She said she would ensure that she received the training she needed to feel comfortable in her job. She said that residents could experience nausea, vomiting, and other illnesses if exposed to expired or contaminated foods or if the kitchen staff were not properly washing their hands. During an interview on 9/7/23 at 9:45 am HSK said that they never go into the kitchen to check the soap, but that they rely on kitchen staff to tell them if it needed to be replaced. Record review of facility policy titled Handwashing - Nutrition Services dated 8/1/18 stated .Hand washing facilities are readily accessible and equipped with paper towels and soap . Record review of facility policy titled Food Storage - Nutrition Services dated 8/1/18 stated .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened . 675358 Page 15 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0880 Provide and implement an infection prevention and control program. 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 maintain infection control prevention and practices for medication administration of eye drops by 1 of 4 staff reviewed for infection control. (MA F) Residents Affected - Few * The facility failed to ensure MA F washed her hands, gloved, and followed policy for administration of eye drops. This failure could place residents at risk of bacterial and viral infections or other diseases from pathogens contracted through contamination of mucosa. Findings included: Record Review of an order summary dated 09/06/23 for Resident #1 indicated she was [AGE] years old admitted [DATE] and with a BIMS score of 15 indicating he was cognitively intact. Resident had a current order for Artificial Tears 1 %-0.2 %-0.2 % eye drops for diagnosis of dry eyes- 1 drops instill in both eyes 2 times per day Wait 5 min between of additional eye drops. During an observation and interview on 09/06/23 at 08:30 AM MA F stated that she worked as a MA for many years. She gathered a tissue and artificial tears for Resident #1 from the medication cart, locked the cart. MA F did not sanitize, wash her hands or glove upon entering the room. MA F asked Resident #1 to tilt her head back for administration and handed Resident #1 the tissue and proceeded to administer eye drops. MA F stated she should have washed her hands before administering the artificial tears and that not doing so could cause infection. When asked if it was policy to also put on gloves, she said she did not know. During an interview on 09/06/23 at 11:50 a.m., the DON said staff were to follow facility policy for administration of eye drops and not doing so put the resident at risk for infection. She stated she would be in servicing staff on hand hygiene and the policy on administration of eye drops. The DON said the staff were monitored for compliance during the annual skills competency. During an interview on 09/07/2023 at 11:15 am the administrator stated the DON and ADON were responsible for training staff on medication administration and infection control. He stated not following infection control guidelines could cause infection. Record Review of a facility policy Titled Medication Administration Eye drops dated 2007 7.11 Eye drops policy indicated .to administer ophthalmic solution into eye in a safe manner . 3. Perform hand hygiene. 4. Shake the eye drops container, if needed. 5. Remove the cap, taking care to avoid touching the dropper tip, place cap on a clean, dry surface (such as a tissue or gauze). 8. With a gloved finger, gently pull-down lower eyelid to form a pouch, while instructing resident to look up. Place other hand against resident's forehead and steady .instill prescribed number of 675358 Page 16 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0880 drops into the pouch near the outer corner of the eye. Level of Harm - Minimal harm or potential for actual harm 16. Remove and dispose of gloves. Discard any barrier for applying or storing the medication and supplies. Wash hands thoroughly with antimicrobial soap and water or facility approved hand sanitizer. Residents Affected - Few 675358 Page 17 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (Administrator, DON, ADON, DM, AD, LVN A, LVN B, LVN C, Rehab Director, CNA D, CNA E, MA F, CNA G, AND CNA H) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, ADON, DM, AD, LVN A, LVN B, LVN C, Rehab Director, CNA D, CNA E, MA F, CNA G, and CNA H. This failure could place staff and residents at risk for not being aware of facility programs, implementation and monitoring. Findings: Record review of personnel files indicated: the Administrator was hired 2/08/2023, the DON was hired 02/06/2023, the ADON was hired on 11/07/2022, DM was hired 6/02/2023, AD was hired 04/01/2010, LVN A was hired 9/14/2022, LVN B was hired on 5/30/2023, LVN C was hired 3/11/2019, Rehab Director was hired 12/01/2001, CNA D was hired 8/15/2019, CNA E was hired 5/30/2023, MA F was 6/08/2022, CNA G was 12/19/2022, AND CNA H was hired on 3/22/2022. Record review of training report indicated the QAPI required training had not been completed on hire for the Administrator, DON, ADON, DM, LVN A, LVN B, CNA E, and CNA G and annually for AD, LVN C, Rehab Director, CNA D, MA F, and CNA H. During an interview on 09/07/23 at 9:47 am the HR stated she started in February 2023 and staff trainings were completed by her or the ADON/DON during orientation for new hires and annually thereafter. She stated the assignments for training were done at corporate and she checked to see that staff were completing the assigned trainings but was not aware of all the required trainings that needed to be assigned. She stated the corporate HR consultant trained her on hire regarding training. She stated she thought QAPI training had been completed by all staff in October 2022 but could not find the training in the online training system. She stated the risk of improper training could affect the staff knowledge on what needs to be done for resident care. During an interview on 09/07/23 at 10:01 am the administrator stated he was responsible for ensuring that all staff receive the mandatory trainings. He stated he was not aware of the new mandatory trainings for QAPI. He stated the corporate office sent the new regulations to the facility administrators, but he had not received the information. He stated the risk of not receiving mandated trainings could have a potential for staff not following guidelines for care. He stated his expectation going forward was that all required trainings were provided to staff as regulated. During an interview on 09/07/23 at 10:36 am the corporate director of clinical education stated the QAPI was assigned to all staff but the system did not reflect the assignment and had reassigned the training effective 09/06/2023. She stated the facility was responsible for ensuring the staff were completing the training on hire and annually. Stated she ran a monthly compliance report and sent the report to the administrator and DON. She stated she was under the impression the facility was monitoring the assignments and ensuring the staff completed the trainings. 675358 Page 18 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0944 Level of Harm - Minimal harm or potential for actual harm Record review of computer-based training assignment report dated 9/7/2023 indicated QAPI was assigned to all staff on 09/06/2023. Record review of facility policy Titled Staff Development dated 06/2013 indicated, .staff development will be provided through ongoing education opportunities including in servicing, training . Residents Affected - Many 675358 Page 19 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide the required compliance and ethics training for 11 of 14 employees (Administrator, DON, ADON, DM, AD, LVN A, Rehab Director, CNA D, CNA E, CNA G, AND CNA H) reviewed for training requirements, in that: Residents Affected - Some The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, ADON, DM, AD, LVN A, Rehab Director, CNA D, CNA E, CNA G, AND CNA H. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings: Record review of personnel file indicated: the Administrator was hired 2/08/2023, the DON was hired 02/06/2023, the ADON was hired on 11/07/2022, DM was hired 6/02/2023, AD was hired 04/01/2010, LVN A was hired 9/14/2022, Rehab Director was hired 12/01/2001, CNA D was hired 8/15/2019, CNA E was hired 5/30/2023, CNA G was 12/19/2022, AND CNA H was hired on 3/22/2022. Record review of training report indicated the Compliance and Ethics required training was not completed on hire for the Administrator, DON, ADON, DM, LVN A, CNA E, and CNA G and annually for the AD, Rehab Director, CNA D and CNA H. During an interview on 09/07/23 at 9:47 am the HR stated she started in February 2023 and staff trainings were completed by her or the ADON/DON during orientation for new hires and annually thereafter. She stated the assignments for training were done at corporate and she checked to see the staff were completing the assigned trainings through the online training system but was not aware of all the required trainings that needed to be assigned. She stated the corporate HR consultant trained her on hire regarding training. She stated the online training system had Compliance and Ethics training entered for 4/28/2022 however there was no report that all staff had completed the training. She stated the risk of improper training could affect the staff knowledge on what needs to be done for resident care. During an interview on 09/07/23 at 10:01 am the administrator stated he was responsible for ensuring that all staff receive the mandatory trainings. He stated he was not aware of the new mandatory trainings for Compliance and Ethics. He stated the corporate office sent the new regulations to the facility administrators, but he had not received the information. He stated the risk of not receiving mandated trainings could have a potential for staff not following guidelines for care. He stated his expectation going forward was that all required trainings were provided to staff as regulated. During an interview on 09/07/23 at 10:36 am the corporate director of clinical education stated the Compliance Ethics training were assigned to all staff last year in April 2022. She stated the facility was responsible for ensuring the staff were completing the training on hire and annually. Stated she ran a monthly compliance report and sent the report to the administrator and DON. She stated she was under the impression the facility was monitoring the assignments and ensuring the staff completed the trainings. Record review of computer-based training assignment report dated 9/7/2023 indicated Compliance and Ethics training was assigned to all facility staff on 04/28/2022. 675358 Page 20 of 21 675358 09/07/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0946 Record review of facility policy Titled Staff Development dated 06/2013 indicated, .staff development will be provided through ongoing education opportunities including in servicing, training . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675358 Page 21 of 21