Health inspection·October 29, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication storage refrigerators reviewed for temperature controls and storage. The facility failed to log and monitor medication refrigerator temperatures for AM and PM as required per facility policy (24-hour periods of time) on 10/02/24 and 10/03/24 for medication storage. The facility failed to log and monitor temperatures twice daily, as required per facility policy, for the month of October 2024 (10/08/24, 10/21/24 and 10/22/24 were the only days logged for the required notations of twice daily medication refrigerator temperature checks for vaccine storage). This failure could place residents at risk of harm by not maintaining proper controlled temperatures for medications, vaccines, and biologicals. Findings included: During an observation and interview on 10/28/24 at 10:28 AM revealed a log was posted on the medication refrigerator that contained vials of flu vaccine, 2 vials of tuberculin skin testing (TST) and 20 unopened insulin pens. The log was not filled out twice daily and had omissions for 24-hour periods of time. The ADON said not monitoring the vaccine and medication refrigerator could result in ineffective medication and vaccine efficiency. The ADON said an in-service would start immediately for correct procedure for recording temperatures for the medication refrigerator and recording per policy. Record review of a temperature log for the month of October 2024 for the only medication refrigerator for the facility indicated: No temperature logged for AM or PM on 10/02/24 and 10/03/24. 10/08/24, 10/21/24 and 10/22/24 were the only days logged for the required notations of twice daily medication refrigerator temperature checks for vaccine storage. During an interview 10/29/24 10:08 AM the DON said not monitoring the medication refrigerator could cause the medication refrigerator to be out of range resulting in loss of vaccine efficiency. The DON said in-services for nursing staff would start immediately and the log would be monitored for compliance. Page 1 of 17 675358 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview 10/29/24 10:09 AM the Administrator said not monitoring the medication refrigerator could cause the medication refrigerator to be out of range resulting in loss of vaccine efficiency. The Administrator said that the DON and ADON were responsible for ensuring the medication storage was monitored for compliance. Residents Affected - Some Record review of a facility policy: dated 01/2024 Medication- Storage of Medication POLICY: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES: . 10. Medications requiring storage at room temperature are kept at temperatures ranging from 15°Celcius (59°F) to 25°Celcius (77°Fahrenheit). Controlled room temperature is defined as 20°Celcius (68°F) to 25°C (77°Fahrenheit). Excursions between 15°Celcius (59°F) to 30°Celcius (86°F) are allowed, with transient spikes to 40°Celcius (104°F) as long as they don't exceed 24 hours. 11. Medications requiring refrigeration or temperatures between 2°Celcius (36°Fahrenheit) and 8°Celcius (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 8°Celcius (46°F) and 15°Celcius (59°Farenheit). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. If using a temperature monitoring device (TMD; digital data logger recommended) that records min/ max temps (I.e., the highest and lowest temps recorded in a specific time period), document current and min/max once each workday preferably in the morning. If using TMD that does not record min/max temps, document current temps twice, at beginning and end of each workday. If no vaccines are stored in the refrigerator, document temperature checks at least once daily. 675358 Page 2 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interviews, and record reviews, the facility failed provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 out of 8 dietary staff. Residents Affected - Few The facility did not ensure Dietary Aide H had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings included : During an observation of the kitchen on 10/27/24 at 9:30 a.m. revealed Dietary Aide H was working in the kitchen as a dietary aide. Review of the food handler's certificates of completion provided by the facility on 10/28/2024, revealed Dietary Aide H did not have a food handler's certificate. An attempted telephone interview on 10/28/2024 at 2:25 p.m. with Dietary Aide H was unsuccessful. During an interview on 10/29/2024 at 9:42 a.m., the Dietary Manager said she was responsible for ensuring staff completed their food handler certification training upon hire and every 2 years. The Dietary Manager said she was unsure why Dietary Aide H had not completed her food handler certification training. The Dietary Manager said Dietary Aide H had been working at the facility for 2-3 months without her food handler's certification, but Dietary Aide H was no longer working at the facility and 10/27/24 was her last day of work. The Dietary Manager said she had not asked Dietary Aide H to get her food handlers certification. The Dietary Manager stated the failure could potentially put residents at risk for food borne illness and cross contamination. During an in interview on 10/29/24 at 9:58 a.m. the Dietician said she had worked for the facility since April of 2024. She said she usually came to the facility every 2 weeks. She said when she came to the facility, she would review all the kitchen systems which included checking for the staffs food handler's certificates. She said she last checked for the food handler's certifications about 2 months ago and Dietary Aide H was working at the facility at that time so she must has missed it that Dietary Aide H did not have her food handler's certification. She said Dietary Aide H had already given notice that she would no longer be working at the facility but said the facility was short on staff on 10/27/24 so the Dietary Manager had asked Dietary Aide H to come in to work. She said by Dietary Aide H working without having her food handler's certification she could possibly handle food inappropriately which could cause residents to become sick by food borne illness. During an interview on 10/29/2024 at 10:40 a.m., the Administrator said he expected the Dietary Manager to ensure the dietary staff had their food handler certificates within 30 days of hire. The Administrator said the importance of obtaining the food handler certificate training was to teach staff to follow proper procedures and prevent infection control issues. The Administrator said the facility did not have a specific policy for obtaining food handler's certification and they followed the Texas Administrative Code. 675358 Page 3 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0802 Level of Harm - Minimal harm or potential for actual harm Record review of the Texas Administrative Code chapter 228 subchapter (b) (d) indicated: All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. Residents Affected - Few 675358 Page 4 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 3 (Residents #4, Resident #13, and Resident #22) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #4, Resident #13 and Resident #22. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: Record review of face sheet dated 10/29/24 for Resident #4 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of cerebral infarction (disrupted blood flow to the brain), dementia unspecified (decline in cognitive abilities), dysphagia (difficulty swallowing). Record review of quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment with a BIMS of 7. Section GG indicated supervision or touching assistance with eating. Record review of a physician's order summary for Resident #4 indicated an order for pureed diet level 4 and thin liquids dated 10/14/24. Record Review of face sheet dated 10/29/24 for Resident #13 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain). Record review of a quarterly MDS dated [DATE] indicated Resident #13 was not assessed for cognition. Section GG indicated Resident #13 required supervision or touching assistance for eating. Record review of a physician's order summary dated 10/29/24 indicated an order for pureed diet level 4 and thin liquids dated 7/11/24. Record review of face sheet dated 10/29/24 for Resident #22 indicated she admitted to the facility on [DATE] and was [AGE] year-old female with diagnoses of vascular dementia (blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior), and vitamin D deficiency. Record review of a quarterly MDS dated [DATE] indicated Resident #13 was not assessed for cognition. Section GG indicated Resident #22 required substantial/maximal assistance for eating. Record review of a physician's order summary dated 10/29/24 indicated an order for pureed diet level 4 and thin liquids dated 6/23/23. During an observation on 10/28/24 10:30 AM revealed [NAME] E began to prepare the puree foods. The 675358 Page 5 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cook was not able to get the puree meatloaf to a smooth texture in the food processor. [NAME] E was observed adding slices of white bread and hot water from a drink pitcher to thin the puree. [NAME] E said it was as smooth as he was going to be able to get it. The puree meatloaf was a chili like texture and not smooth. When pureeing the English peas [NAME] E was not able to get a smooth consistency. The cook was observed adding sliced white bread to the peas and hot water from a drink pitcher to thin the puree peas. [NAME] E said that it was the same texture that he normally served. The Dietary Manager went and got the Administrator to observe the surveyor's concern and the Administrator directed the cook not to serve the puree meatloaf or peas at that time. The Administrator said he was going to consult with the Dietician and come up with backup plan to serve the purees for lunch. [NAME] E said he was told by a dietician to add bread and hot water to all puree foods because it enhanced the flavor of the food. During an observation on 10/28/24 at 11:30 AM the Dietary Manager was observed pureeing boneless pork ribs in the food processor, she was using milk to thin the mixture. She said she had spoken with the Dietician and said she was instructed wrong about adding bread and hot water to the puree mixtures. SLP J and SLP K were present for the making of the puree boneless pork ribs and green beans and agreed the mixture was safe for resident consumption. During an interview on 10/29/24 at 10:30 a.m. [NAME] E said the Dietician before the current Dietician told him to add bread to the puree foods because it added flavor and texture to the foods, and that a chef had taught her that. He said he always used hot water to thin out the purees because the Dietician saw him thinning the mixture with milk and told them they did not have to use milk, they could use water. He said it was the same dietician that told them to use bread. During an interview on 10/29/24 09:42 AM the Dietary Manager said she had worked at the facility for about 1 1/2 years. She said the previous Dietician told her the correct way to puree foods was to add white bread and hot water; she said before that she was using milk or broth and was not adding bread. She said on 10/28/24 when she told her current Dietician they were adding bread and hot water to the puree foods she was told that was not the correct way. She said the residents could choke if the texture was not correct. The Dietary Manager said she had worked at other facilities and did not think the texture was as smooth as purees she had made at other facilities. During an interview on 10/29/24 at 9:58 a.m. the Dietician said she had been the dietician since April of 2024. She said she came to the facility every 2 weeks. The Dietician said she had not watched the pureeing process but had checked the food consistency and it was appropriate. She said she had always found pureed foods to be adequate during her visits. The Dietician said she was not aware they were using bread and hot water to mix puree foods. She said per the recipes they indicated to use broth or milk, gravy, sauces, or butter to mix puree foods. She said the Dietary Manager had been told by the previous Dietician to use bread and hot water and that was not correct, and she had not watched the puree process, so she had missed that. The Dietician said by not following the proper way to puree foods it could cause the resident to aspirate (accidental breathing in food into the lungs). She said by adding water to the puree food it was not adding any flavor or calories and by adding bread it would skew portion sizes. She said the residents would receive insufficient protein, vitamins and minerals and could possibly cause weight loss but was more concerned with missing the micronutrients. During an interview on 10/29/24 at 10:40 a.m. the Administrator said pureed foods should be nutritional and palatable and a smooth consistency. He said water should never be used to thin puree foods. He said if the pureed foods were not prepared correctly the resident would not get the full 675358 Page 6 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0805 nutritional value of the food. Level of Harm - Minimal harm or potential for actual harm Record review of the undated recipe for Seasoned Peas indicated: Dysphagia/Puree: place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, add 3 TBSP thickener and ¼ C hot liquid (cooking liquid, water, or broth); process until smooth. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds. Press the pureed vegetables through a cone shaped sieve (a chinois Strainer) with a pestal or a spoon to remove any hulls. Reheat to 165*F and serve with a #12 scoop. Residents Affected - Some Record review of the undated recipe for Meatloaf/Ketchup Sauce indicated: Dysphagia/Puree: place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 1 TBSP thickener and ½ cup hot liquid; mix well with a wire whip. Add ½ of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds. Reheat to 165*F and serve with a #8 scoop. Record review of the undated recipe for Green Beans indicated: 1. Remove portions needed from regular prepared recipe; drain and reserve liquid. 2. Place drained portions into a food processor; process to a fine texture. 3. Add thickener and liquid. Process until smooth. With a rubber spatula scrape down the sides of the bowl; reprocess 30 seconds. 4. Reheat to 165*F and serve. Record review of the undated recipe for BBQ Pork Rib indicated: place portions needed into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 4 TBSP thickener and 3/4 cup hot water; mix well with a wire whip. Add ½ of the slurry to the meat. process for 1 minute. If too dry, add more slurry until pudding consistency is achieved. Reheat to 165*F and serve with a #8 scoop. Record review of the facility's policy titled Use of Recipes dated August 1, 2018, indicated: 3. Nutrition Services employees are expected to use and follow the recipes provided. 675358 Page 7 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerator were not kept past their expiration dates. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on 10/27/2024 at 9:30am, the following items were observed: (2) 32-ounce containers of vanilla Greek yogurt with the expiration date on 10/22/24. During an interview on 10/29/24 at 9:05 a.m. [NAME] E said it was everyone's responsibility to check for expired foods in the fridge. He said they threw away expired foods. He said the Dietary Manager check ed for expired foods in the separate storage area. He said he had checked the refrigerator Thursday 10/24/24 for expired food and did not see the expired food. He said he did not have time to look at every expiration date on every product because he basically had 6 meals a day to cook. He said the residents could get sick from consuming expired foods such as diarrhea or upset stomach. During an interview on 10/29/24 at 9:21 a.m. Dietary Aide G said she had worked at the facility since August 27th 2024. She said it was everyone's responsibility to check for expired foods in the refrigerator. She said she did it to help out, but she is not sure whose job it was to check for the expired foods. She said residents could get sick by consuming expired foods. During an interview on 10/29/24 at 9:42 a.m. the Dietary Manager said she had worked at the facility for about 1 1/2 years. She said it was everyone's responsibility to check for expired foods. She said on Fridays she checked for expired foods when she gets her food truck. She said if the residents consumed expired foods, they could get sick. During an interview on 10/29/24 at 9:58 a.m. the Dietician said she had been coming to the facility since April of 2024. She said staff should be checking for expired foods daily. She said the Dietary Manager was supposed to do a daily checklist and checking for expired foods was on the list to be done daily. She said food borne illness was a potential risk to the resident for consuming expired foods. During an interview on 10/29/24 at 10:40 a.m. the Administrator said all foods should be used or disposed of by the use by date. He said food borne illness was a potential risk to the resident for consuming expired foods. Record review of undated Daily Quick check of Kitchen/Foodservice Operations checklist indicated: .Refrigerators . No expired foods . 675358 Page 8 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0812 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Food Storage dated August 1, 2018, indicated: Sufficient storage facilities are provided to keep foods safe. Wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 2. Refrigerator: .All foods are covered, labeled and dated. Residents Affected - Few 675358 Page 9 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: Residents Affected - Few The facility did not ensure the gas stove was in working order. One of six gas stove burners (right back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation on 10/27/24 at 9:30 a.m., revealed the gas stove had six burners and one burner located in the right back had excess carbon buildup. The right back burner would not light automatically. During an interview on 10/27/24 09:30 a.m. [NAME] F said that the burner would not light last week. She said the Maintenance Director fixed the oven about 1-2 months ago and the burner had been working up until last week. During an interview on 10/29/24 at 8:25 a.m., the Maintenance Director said he had worked at the facility for 6-7 years. He said no one had notified him that the burner on the stove was not working until Sunday 10/27/24. He said he cleaned the burner on Sunday 10/27/24 and the burner started lighting. He said sometimes when the kitchen staff were cooking, they dropped grease on the burners, and they would get clogged up and not light. He said sometimes he had to use a drill bit and clean the burner holes due to the buildup of grease. He said if the stove burner was not lighting appropriately the kitchen could fill up with gas. During an interview on 10/29/24 at 9:05 a.m. [NAME] E said he had worked at the facility for about 10 months. He said he worked on Friday 10/25/24 and did not use the right back burner. He said sometimes the burners wouldn't light and he would use a lighter to light the burners. He said the last time he used the right back burner was sometime last week and it was working. He said he clean ed the stove grates every day at the end of his shift. He said the Maintenance Director cleaned the actual burner and said it was last month when that was done during mock survey. He said the burners had buildup on them then. During an interview on 10/29/24 at 9:42 a.m. the Dietary Manager said she had worked at the facility for about 1 1/2 years. Said she was not aware of the back stove burner not lighting until Sunday 10/27/24 upon surveyor entry. She said she would report any stove issues to the Maintenance Director. She said on Sunday 10/27/24 the Maintenance Director came to look at the stove after she reported to him the right back burner was not working. She said the stove burners had never had any issues not working prior to Sunday 10/27/24. She said if the stove was not working properly, they could smell gas and it could make employees and residents sick. During an interview on 10/29/24 at 9:58 a.m. the Dietician said she had been coming to the facility since April of 2024. Said she comes into the facility every 2 weeks. She said she reviewed all the systems, equipment, pantry's, food prep areas looking for broken equipment, and cleanliness. She 675358 Page 10 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she was at the facility last week and checked the stove because the stove was an issue during mock survey. She said she observed the Maintenance Director cleaning the stove due to excessive build up on the burners. She said she did observe the burners at that time and they all lit. During an interview on 10/29/24 at 10:40 a.m. the Administrator said all equipment should be maintained by the Maintenance Director. He said the potential hazard for the stove not working properly was it could lead to fire. Record review of facility policy titled Maintenance Schedules undated indicated: Preventive maintenance schedules shall be developed and implemented to assure that the building and equipment are maintained in a safe and operable manner. 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 675358 Page 11 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 dining rooms (400 hall Dining Room), 1 of 4 halls (400 hall) and 1 of 6 (Resident #33) residents reviewed for environment. The facility failed to ensure that the 400-hall dining room and floors and walls were clean and maintained in good repair on 10/27/24. The facility failed to ensure the 400 hall walls and floors were maintained in good repair on 10/27/24. The facility failed to ensure Resident #33's box fan was free of dust and debris on 10/27/24. These failures could affect residents and the staff by placing them at risk for diminished quality of life and injury due to lack of a sanitary and well-kept environment. Findings: 1.During an observation on 10/27/24 at 9:09 am revealed the dining room floors located on hall 400 were dirty with a sticky substance and dark colored grime. There was a dark, black, thick buildup around the edges of all the walls. The base boards located in the dining room were torn, black and brown stained , and pulled away from the wall. There were chips in the paint throughout the dining room and the edges of the wall s throughout the dining room were torn exposing the sheetrock. There were dried discolored substances on the walls near the sink areas as well as under the sinks. During an observation on 10/27/24 at 9:12 am revealed there was black tape material on the floor at the exit door on hall 400 that was torn and raised from the floor. The wall going into the shower room hallway had breaks in the sheetrock. During an interview on 10/27/24 at 9:49 am the Floor Tech said he and the housekeeping staff were responsible for the floors in the facility. He said he had not had a chance to deep clean the dining room in several months but tried to do it monthly and as needed. He said as far as the tape at the exit door on 400 hall the Maintenance Director was responsible for changing it, but he cleaned around it the best he could. He said the residents could fall on the torn tape at the door and the floors not being clean could cause infections. During an interview on 10/28/24 at 9:43 am the Housekeeper B said she had been in housekeeping for a year, and she swept and mopped the dining room on 400 hall every day. She said she was not sure who did the deep cleaning to remove the buildup on the floors and walls, but it probably should be housekeeping. She said the floors in the halls were the responsibility of the Floor Tech and the damaged items were to be fixed by maintenance. She said if the area was not kept clean and in good repair it could cause resident injury or sickness. During an interview on 10/28/24 at 12:13 pm the Maintenance Director said he had been at the facility 6 years and was responsible for all maintenance in the facility. He said he was aware of the damaged areas on 400 hall and was in the process of starting repairs. He said the tape at the exit door 675358 Page 12 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had been there for many years and he had not noticed how worn and torn it was. He said damaged areas could cause resident injury. During an interview on 10/29/24 at 10:29 am the Administrator said that the housekeeping staff and Floor Tech were responsible for ensuring the floors and walls were clean and the Maintenance Director was responsible for all repairs in the facility. He said he was aware of the damaged areas on 400 hall and was in the process of getting to the repairs but was not aware of the uncleanliness of the dining room. He said if the environment was not maintained it could affect the residents safety and psychosocial wellbeing. He said he expected the facility to have a safe and clean environment for all residents. 2. Record review of a face sheet dated 10/28/2024 for Resident #33 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of chronic obstructive pulmonary disease (inability to maintain adequate oxygen exchange in the blood), vitamin deficiency, lack of coordination, and anxiety disorder (excessive worry about everyday issues and situation). Record review of a Quarterly MDS Assessment for Resident #33 dated 9/30/2024 indicated she had severe impairment in thinking with a BIMS score of 4. She required oxygen 7 days per week continuously and respiratory therapy 7 times per week for at least 15 minutes. Record review of a care plan dated 9/25/2024 for Resident #33 indicated she had an altered breathing pattern problem related to COPD and interventions included to provide oxygen per nasal cannula continuously. During an observation and interview on 10/28/24 at 10:10 am revealed a box fan was running and sitting on the floor blowing toward Resident #33. The protective grill (fan cage) had dark brown dust and lint build up, area 15 inches by 20 inches with lint and brown matter dangling in the air current. Resident #33 said that she had the fan on to help her breathe since she had difficulty and used oxygen constantly. Resident #33 said the fan heled her feel better when she had increased symptoms from her COPD. Resident #33 said she had not noticed the fan was so dirty and had never observed anyone cleaning it. During an interview on 10/28/24 at 2:23 am Housekeeper B said she did not know who was responsible for cleaning fans in resident rooms. She said she had cleaned one before but not the one in Resident #33's room. She said she did not know who the housekeeping supervisor was or who her direct report was. She said not keeping equipment clean for resident use could cause the resident harm by spreading germs, dust and give them a feeling of not being in a clean place to live. During an interview on 10/28/24 at 2:31 am the DON said that it was housekeeping's responsibility to clean any equipment used for the residents. She said that she would get the fan cleaned right away. She said she would notify the Administrator since there was no housekeeping supervisor and start an in-service with the housekeeping staff. She said the risk to the resident could be blowing particles of lint and dust and cause exacerbation of symptoms of COPD for Resident #33. During an interview on 10/29/24 at 08:45 am the Maintenance Director said the housekeeping department would be responsible for cleaning of the fans and other equipment used for the residents. He said not cleaning the fan was unsanitary and could cause the resident risk of breathing lint and particles. 675358 Page 13 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/29/24 at 11:13 am the Administrator said the housekeeping department would be responsible for cleaning of the fans and other equipment used for the residents. He said not cleaning the fan was unsanitary. Record review of an undated facility policy titled Maintenance Services indicated, .I. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance, but are not limited to: b. Maintaining the building in good repair and free from hazards . 675358 Page 14 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 an effective pest control program to ensure the facility was free of pests for 2 of 4 hallways, (hallway 200 and 400), 2 resident rooms (Resident #33 and Resident #15 rooms) and two of two dining areas (main and locked unit dining areas) reviewed for pest control. Residents Affected - Many The facility failed to ensure hallways, resident rooms and dining rooms were free of flies. This failure could place residents at risk of a diminished quality of life due to an unsanitary environment. Findings include: Record review of a face sheet dated 10/28/2024 for Resident #33 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of chronic obstructive pulmonary disease (inability to maintain adequate oxygen exchange in the blood), vitamin deficiency, lack of coordination, and anxiety disorder (excessive worry about everyday issues and situation). Record review of a Quarterly MDS Assessment for Resident #33 dated 9/30/2024 indicated she had severe impairment in thinking with a BIMS score of 4. During an observation and interview on 10/27/24 at 10:30 AM revealed Resident #33 had several flies in her room crawling on her bed and table. Resident #33 said the flies come and go; she really doesn't pay them any attention because they were always here. Record review of a face sheet dated 10/28/2024 for Resident #15 indicated she admitted to the facility on [DATE] and was an [AGE] year-old female with diagnoses of hypertension and chronic pain. Record review of a Quarterly MDS Assessment for Resident #15 dated 10/02/2024 indicated she was cognitively intact with a BIMS score of 13. During an observation and interview on 10/27/24 at 10:45 AM revealed 2-3 flies were flying inside Resident #15's room, and a fly swatter was on the bedside table. Resident #15 said that flies were a problem at the facility because of a pasture behind the facility just had chicken litter applied and that created lots of them. During an observation on 10/27/24 at 11:08 AM revealed flies down hallway 200 crawling on doorways and on a Hoyer lift sitting out in the hallway. There were no operating blowers at doorways at the facility entrance or at the exits on 200 and 400 hallways. During an observation on 10/27/24 at 11:50 AM revealed Resident #15 arrived at the dining room with a fly swatter on her rolling walker. During an observation on 10/27/24 at 12:10 PM of the lunch meal in the dining room, revealed 1-2 flies crawling on 4 of 7 tables. Flies were crawling on the front right table onto Resident #15's plate and over the vegetables. Resident #15 swatted a fly away with her hand then continued to eat. 675358 Page 15 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 10/27/24 at 2:15 PM Resident #15 said the flies were a nuisance and she kept a swatter with her during meals and at her bedside. During an observation and interview on 10/28/24 at 4:11 PM revealed a blower on the kitchen door was turned off. The DM said the blower worked but she wasn't sure how to turn it on and went to ask the Maintenance Director . The DM returned to the kitchen and turned the blower on, and the blower started working. The DM said typically the blower was on and they did not have any problem with flies in the kitchen. During an observation on 10/28/24 at 12:11 PM flies in the Locked Unit Dining room revealed flies crawling on the table and down the hallway crawling on doorways During an observation on 10/28/24 at 12:11 PM revealed there were flies present in the 400-hall dining room and the 400- hall hallway. The flies were on resident food. During an interview on 10/28/24 at 12:15 PM CNA A said the flies were better than they were but still present in the facility. She said they swatted them daily, but they kept coming back. She said the flies in the facility could affect sanitation. During an interview on 11/29/24 at 10:30 AM the Maintenance Director said the pest control company came monthly to treat for pests in general. He said the facility had issues with flies since the summer. He said they were bad in July 2024 but were better. He said the pasture behind the facility had chicken litter spread (raw fertilizer) recently and that increased the number. He stated he did not know the risk of having flies other than it being unsanitary. The Maintenance Director said he did not know why the blower located at the kitchen doorway was turned off. He said the blower being turned off could cause flies to enter the facility. The Maintenance Director said no one had logged a request for interventions for the flies and no one had told him that flies were an increased problem in the facility. He said if he knew it was a problem, he could have asked for additional interventions from pest control service to control the flies. During an interview on 11/29/24 at 11:00 AM the Administrator said pest control comes to the facility bi-monthly. The Administrator said they had provided residents fly swats to help with fly control. The Administrator said that keeping the blower on at the kitchen door would help keep flies out of the facility. He said the risk to the residents was unsanitary conditions when flies were in the building, risk of flies carrying infection and not a homelike environment. Record review of pest control bi- monthly visit summary reports dated from July 2024 to September 2024 indicated the facility had no specific treatment for flies at bi- monthly visits. Record review of a facility policy undated titled Pest Control indicated, Our facility shall maintain an effective pest control program . this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents . Maintenance services assist, when appropriate and necessary, in providing pest control services . 675358 Page 16 of 17 675358 10/29/2024 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for the 1 of 1 facility . Residents Affected - Few The facility failed to ensure the staff were smoking in the designated smoking area and disposing of smoking materials properly on 10/27/24. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings: During an observation on 10/27/24 at 9:40 AM revealed cigarette butts were observed in a plastic cup on the ground outside the exit door located on 400 hall and there were four cigarette butts sitting on the outside keypad next to the door. During an interview on 10/27/24 at 9:42 AM LVN C said there were no residents that smoked on the 400 hall and the cigarette butts belonged to the staff. She said there was a smoking area out back and the area outside the exit door was not a designated area to smoke. She said if smoking occurred in undesignated areas there could be risk of fires. During an interview on 10/27/24 at 9:44 AM CNA D said she worked on 400 hall and the cigarette butts were hers. She said the designated area was out back, but she could not leave and thought it was ok for her to smoke in that area. She said she would pick up her cigarette butts and throw them away at the end of her shift. She said by not smoking in the designated area and properly disposing of her cigarette butts it could cause a fire. During an interview on 10/28/24 at 8:42 AM the Administrator said the only designated smoking area was located outside the main dining room and he was not aware staff were smoking outside 400 hall. He said the smoking policy was directed to the residents smoking but he expected all staff to following the smoking rules and only smoke in the designated area per the staff handbook. He said that smoking in undesignated areas could be a fire risk. Record review of an undated facility floor plan indicated designated smoking area outside the main dining room. Record review of a facility team member handbook titled Smoking indicated, .Team members may smoke on their rest breaks and meal periods in designated smoking areas outside the facility. Team members must discard smoking materials in appropriate receptacles and not on the ground . 675358 Page 17 of 17