Health inspection·May 8, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 4 residents (Resident #94) reviewed for reasonable accommodations and preferences, in that: Residents Affected - Few The facility failed to ensure Resident #94's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. Findings include: Record review of Resident #94's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), HIV [human immunodeficiency virus] (a virus that attacks the body's immune system), and Encephalopathy (means damage or disease that affects the brain). Record review of the Quarterly MDSn dated 2/19/24, reflected BIMS score of 11 which reflected moderate cognitive impairment. Review of Resident #94's Quarterly MDS, dated [DATE], reflected under section G, G0300, option #3, which stated that the patient was unsteady on his feet and required assistance X 1. Record review of Resident #94's care plan, dated 4/17/23, revealed the resident had a communication problem with interventions, ensure call light is within reach. Observation on 5/06/24 in Resident #94's room at 10:28 a.m. revealed the call light was not visible. Resident #94's call light was on the floor. During an interview with Resident #94 on 5/06/24 at 10:25 a.m., the resident stated he did not know how the call light got on floor. During an interview with CNA WW on 5/06/2024 at 10:55 a.m., CNA WW stated she was the assigned nursing assistant for Resident #94. The call light was on the floor, and CNA WW did not know how it got on the floor. CNA WW picked up the call light and clipped it to Resident #94's pillow. CNA WWstated Resident #94's lack of access to a call light could negatively affect him if he got up without Page 1 of 24 675409 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0558 assistance and fell. Level of Harm - Minimal harm or potential for actual harm In an interview with the DON on 5/6/24 at 11:05 a.m., the DON stated that all lights should be within arm's length of all residents. The DON further stated the lack of accessibility to a call light could possibly lead to a fall if a resident needed something. The DON stated the ADONs monitored this task daily during morning rounds, and he was responsible for ever seeing this task. Residents Affected - Few Record review of the facility's policy titled, Call Lights: Accessibility and Timely Response, dated 10/13/22, revealed the call light system will be available to all residents. 675409 Page 2 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #42) reviewed for privacy, in that: Residents Affected - Few CNA C and CNA D did not close Resident #42's window privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #42's face sheet, dated 05/07/2024, revealed an admission date of 03/14/2014 and, a readmission date of 05/10/2021, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Parkinsonism (Group of neurological conditions that cause difficulty with movement), Hypertension (High blood pressure), Epilepsy (unprovoked recurrent seizures), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #42's Annual MDS assessment, dated 03/26/2024, revealed the resident had a BIMS score of 7, indicating she was severely impaired. Resident #42 was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #42's care plan, dated 08/14/2018, revealed a problem of The resident has an ADL self-care performance deficit related to Confusion,Dementia, Disease Process (Parkinson's), Limited Mobility, EPS, with an intervention of TOILET USE: The resident requires extensive assistance by 1 staff for toileting. Observation on 05/07/2024 at 1:01 p.m. revealed CNA C and CNA D did not completely close the window curtain while they provided incontinent care for Resident #42, exposing the resident by the window. During an interview with CNA C and CNA D on 05/27/2024 at 1:13 p.m., CNA C and CNA D confirmed the window curtain was not completely closed while they provided care for Resident #42 but it should have been. They confirmed they received resident rights training within the year. During an interview with the DON on 05/07/2024 at 1:30 p.m., the DON confirmed privacy must be provided during nursing care and Resident #42's window curtain should have been closed completely. He confirmed the staff had received training on resident rights within the year and the training was provided by the ADONs They also check the staff skills annually and as needed. Review of the facility's policy titled Statement of Resident Rights, undated, revealed, You have a right to: [ .] privacy, including during visits and telephone calls. 675409 Page 3 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #21) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #21 who eloped from the facility on 05/02/24. An Immediate Jeopardy (IJ) was identified as past non-compliance on 05/07/24. The non-compliance began on 05/02/24 and ended on 05/04/24. The facility had corrected the non-compliance before the survey began on 05/05/24. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Record review of the face sheet for Resident #21 dated 5/6/24 revealed the 55- year- old male resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: unspecified dementia (a condition of cognitive impairment that can have occur for various reasons), schizoaffective disorder (a condition that affects a person's mood and ability to think and behave clearly), and anxiety disorder (a condition in which there are strong feelings of worry or fear). Record review of Resident #21's Annual MDS dated [DATE] revealed the resident had a BIMS score of a 9 which indicated that the Resident was cognitively impaired. The MDS indicated that the resident exhibited a significant risk of wandering behavior. Record review of the Quarterly care plan for Resident #21 dated 4/10/24 revealed the resident had a risk of elopement potential. The interventions included identifying the pattern of wandering and distracting the resident from wandering with pleasant diversions and structured activities. Further review revealed the resident's care plan was changed on 5/2/24 to include the resident's elopement on 5/2/24. Record review of wandering assessment for Resident #21 dated 7/27/23 noted the resident had a history of wandering and was a risk for wandering behavior to continue. The wandering assessment was revised on 5/2/24 to include the elopement incident. Record review of the physician order summary for Resident #21 dated 5/8/24 revealed the resident was under the care of psychiatric services for medication management and behavior monitoring. Record review of the one-on-one supervision log for Resident #21 dated 05/08/24 revealed the resident was under continuous one-on -one supervision by nursing staff since return to the facility from the elopement with the plan for the on-on-one supervision to be continued. Observation from 05/05/24 to 05/08/24 between the hours of 8:00 a.m. and 4:00 p.m., of all the resident corridor hallways revealed the door alarms were in working order. 675409 Page 4 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview with the DON on 5/6/24 at 11:15 a.m. regarding the elopement incident., the DON stated that Resident #21 had eloped from the facility on 5/2/24 during the 4:00 p.m. smoke break. The DON stated that at the initiation time of the smoke breaks the hall corridor doors alarms for the four resident hallways were disengaged by the activity staff to allow the residents to enter the outside smoking area and then re-engaged when the smoke break was over. The DON stated on 5/2/24 Resident #21 had not joined the resident smoking group but instead walked independently around the fence perimeter and proceeded to remove several of the boards from the eight- foot- high fence and scaled the fence to leave the facility property at 4:20 p.m. The DON further stated that upon noticing the fence breakage, the staff began an immediate elopement protocol which included resident head count to determine that Resident #21 was missing along with notification of the local police department, the physician, and the resident's responsible party. The DON stated that multiple facility staff also conducted a grounds and neighborhood hood search for the resident who was located at 5:15 p.m. several blocks away from the facility and was then returned to the facility. The DON stated a complete Head- to- Toe assessment of Resident #21 was completed and revealed no injuries. The DON stated that the resident said he was glad to be back at the facility and had been looking for a soda and a bakery. The DON stated that upon Resident #21's return to the facility, the resident was placed immediately on 24 hour one-on-one supervision. The DON further stated that the practice of the hall corridor alarms being de-activated during the smoke breaks was immediately terminated and all hall corridor door alarms would stay activated at all times. The DON stated that the resident's 24/7 one-on-one supervision would continue until a new fencing structure was put into place on the facility grounds which would restrict all resident access to any outside area which was not in direct visual observation of the staff who were outside with the residents. The DON stated that he and the ADON staff routinely did outside perimeter rounds of the facility ground several times a day. During an interview with the Administrator on 5/6/24 at 1:45 p.m., the Administrator stated that he had ordered that all resident corridor doors keep their door alarms engaged at all times. The Administrator further stated that he had approved the construction of a 10- foot tall fence on the outside grounds of the facility which would restrict resident access to only being under the direct visual observation of the staff at all times. During an interview with the Regional [NAME] President for Operations on 5/6/24 at 1:50 p.m., the Regional [NAME] President for Operations stated that he had authorized the financial payment for the facility's fence construction to prevent resident elopement. During an interview with the Maintenance Director on 5/6/24 at 3:00 p.m., the Maintenance Director stated that he completed regular inspections of the outside fence area surrounding the facility for structural integrity. The Maintenance Director further stated that the resident hallway door alarm codes were changed on a monthly basis. The Administrator was notified on 5/7/24 at 4:00 p.m., that a past non-compliance IJ situation had been identified due to the above failure. It was determined the failures placed Resident #21 in an IJ situation on 5/7/24. The facility implemented the following interventions. During an interview with CNAs M and N on 5/6/24 from 3:10 p.m. to 3:20 p.m., CNAs M and N stated they completed three outside perimeter checks of the facility perimeter during their 2:00 p.m. to 10:00 p.m. shift assignments. 675409 Page 5 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interviews on 5/6/24 at from 4:15 p.m. to 4:54 p.m. the Housekeeping Supervisor, 8 CNAs (P, Q, R,S, T, U, V and X), NA W, 4 LVNs (Y, AA, DD And BB), 2 RNs (The DON and Z ), Activity Aide CC who stated they had received the facility in-service on elopement conducted from 5/2/24 -5/4/24 and which included: information on a-routine resident 2 hour checks, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. The Housekeeping Supervisor stated that the staff work as a team to prevent resident elopements which included 3 facility perimeter checks during the 2-10:00 p.m. shift. During an interview on 5/7/24 from 8:00 a.m. to 8:34 a.m. with 10 CNAs (EE, C, FF, GG, HH, II, JJ, D, E, KK) 7LVNs (LL, MM, ADON A, ADON B, OO, QQ, and G) RN PP at 8:00 a.m., who confirmed she had received the facility in-service on elopement conducted from 5/2/24 -5/4/24 and which included: information on a-routine resident 2 hour checks, awareness of the elopement binder, and monitoring residents for exit seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility. The CNA EE stated that the staff work as a team to prevent resident elopements which included facility perimeter checks during the 2:00 p.m.-10:00 p.m. shift. Record review of the fence construction estimate at the facility, dated 5/7/24 revealed the estimate was approved. Record review of the facility's policy titled, Elopements and Wandering Residents, dated 11/21/22, revealed, the facility is to ensure that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents and receive care related to their elopement risk. 675409 Page 6 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 resident (Resident #29) reviewed for incontinent care, in that: While providing incontinent care for Resident #29, CNA E did not clean between Resident #29's buttocks'' cheeks and CNA E did not use the right technique to clean Resident #29's penis. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #29's face sheet, dated 05/07/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/25/2021, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (Under active Thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Liver disease (loss of liver function), Chronic kidney disease (Gradual loss of kidney function), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #29's Quarterly MDS assessment, dated 02/23/2024, revealed Resident #29 has a BIMS score of 4, which indicated severe cognitive impairment. Resident #50 was indicated to frequently be incontinent of bowel and bladder. Record review of Resident #29's Optional State assessment dated [DATE] revealed Resident #29 required extensive assistance with his activity of daily living. Review of Resident #29's care plan, dated 07/02/2021, revealed a problem of The resident has potential skin integrity related to Debility as evidence by decreased bed mobility, incontinent of bowel and bladder habits, History of cellulitis to Right forearm., with a goal of of The resident will maintain or develop clean and intact skin by the review date. Observation on 05/07/24 at 10:06 a.m. revealed, while providing incontinent care for Resident #29, CNA E used a base to tip motion to clean Resident #29 penis, instead of a tip to base motion. CNA E did not clean the buttocks or anal area of the resident. During an interview on 05/07/2024 at 10:20 a.m. CNA E revealed she thought she was using the tight technique to clean Resident #29's penis. She conformed she should have clean from tip to base. She confirmed she did not clean the resident buttocks area but she thought she did not have to do it. She confirmed she should have cleaned the anal area. She confirmed receiving training for infection control and incontinent care within the last year. During an interview with the DON on 05/07/2024 at 1:30 p.m., the DON confirmed the correct way to clean a male resident during incontinent care was from tip to base and the buttocks and anal area 675409 Page 7 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0690 Level of Harm - Minimal harm or potential for actual harm have to be cleaned. The DON revealed ADONs were the ones training the staff for infection control and incontinent care and that they would check the staff skills annually and as needed if a problem was noted. Review of facility policy, titled Perineal care, dated 10/24/2022, revealed [ .] Cleanse the shaft of the penis, using downward strokes toward the scrotum [ .] clean and dry the bottom of the scrotum and the anal area. Residents Affected - Few 675409 Page 8 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 4 residents (Resident #29) by 1 of 4 certified staff (CNA E) reviewed for competent staff, in that: 1. While providing incontinent care for Resident #29, CNA E did not clean between Resident #29's buttocks'' cheeks and CNA E did not use the right technique to clean Resident #29's penis. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings included: Record review of Resident #29's face sheet, dated 05/07/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/25/2021, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (Under active Thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Liver disease (loss of liver function), Chronic kidney disease (Gradual loss of kidney function), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #29's Quarterly MDS assessment, dated 02/23/2024, revealed Resident #29 has a BIMS score of 4, which indicated severe cognitive impairment. Resident #50 was indicated to frequently be incontinent of bowel and bladder. Record review of Resident #29's Optional State assessment dated [DATE] revealed Resident #29 required extensive assistance with his activity of daily living. Review of Resident #29's care plan, dated 07/02/2021, revealed a problem of The resident has potential skin integrity related to Debility as evidence by decreased bed mobility, incontinent of bowel and bladder habits, History of Cellulitis to Right forearm., with a goal of of The resident will maintain or develop clean and intact skin by the review date. Observation on 05/07/24 at 10:06 a.m. revealed, while providing incontinent care for Resident #29, CNA E used a base to tip motion to clean Resident #29 penis, instead of a tip to base motion. CNA E did not clean the buttocks or anal area of the resident. During an interview on 05/07/2024 at 10:20 a.m. CNA E revealed she thought she was using the tight technique to clean Resident #29's penis. She conformed she should have clean from tip to base. She confirmed she did not clean the resident buttocks area but she thought she did not have to do it. She confirmed she should have cleaned the anal area. She confirmed receiving training for infection control and incontinent care within the last year. During an interview with the DON on 05/07/2024 at 1:30 p.m., the DON confirmed the correct way to clean a male resident during incontinent care was from tip to base and the buttocks and anal area 675409 Page 9 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0726 Level of Harm - Minimal harm or potential for actual harm have to be cleaned. The DON revealed ADONs were the one training the staff for infection control and incontinent care and that they would check the staff skills annually and as needed if a problem was noted. Review of annual skills check for CNA E revealed CNA E passed competency for Perineal care/incontinent care on 05/12/2023. Residents Affected - Few Review of facility policy, titled Perineal care, dated 10/24/2022, revealed [ .] Cleanse the shaft of the penis, using downward strokes toward the scrotum [ .] clean and dry the bottom of the scrotum and the anal area. 675409 Page 10 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 of 4 residents (Resident #70) reviewed for accuracy of medical records in that: The facility failed to ensure Resident's#70 order of Lorazepam 0.5 mg every 4 hours X 2 doses. However, the order did not have a stop date. The findings included: Record review of resident #70 Face sheet dated 5/6/24 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included post-traumatic disorder (a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances), Benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous leading to urine obstruction), and anxiety disorder (a disorder that involves persistent and excessive worry that interferes with daily activities). Record review of Resident #70 Quarterly MDS assessment, dated 4/12/24, revealed the resident had a BIMS score of 8, which indicated mild impairment. Record review of Resident #70 Physician monthly orders for May 2024 , revealed an order for Lorazepam 0.5 mg administer one tablet every 4 hours X 2 doses, indefinite order , no stop date . Record review of Resident #70's MAR revealed Resident #70 had not received Lorazepam 0.5 mg for month of May 2024. Interview with Resident #70 on 5/6/24 at 2:00 p.m., the resident stated he did not recall when he last received as needed medication lorazepam. Interview with LVN VV on 5/6/24 at 210 p.m., LVN VV stated any PRN orders for any antianxiety medication should only be written for 14 days and then reviewed by a physician. LVN VV stated that the nurse who wrote the order must have checked the order as indefinite instead of 14 days. LVN VV stated Resident #70 had received the order only once, back in April 2024, but could not find the narcotic sheet as the medication Lorazepam had been destroyed by the pharmacist and the DON during monthly drug destruction. LVN VV stated that Resident # 0 risked possibly receiving more doses than ordered of Lorazepam, which could lead to drug dependence and falls. In an interview with the DON on 5/6/24 at 2:30 p.m., the DON stated the order for Lorazepam 0.5 mg should have been written with an end date after 14 days or order written. The DON stated he did not know why the admitting nurse wrote the order with no stop date. The DON stated Resident #70 risked possibly receiving medication past the recommended time frame. The DON state the ADONs were responsible for monitoring this task daily, he was responsible for overseeing this task, and the facility did not have a policy to cover this scenario. 675409 Page 11 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 3 of 3 residents (Residents #43, #79, and #91) reviewed for medications, in that: LVN LL pre-poured medications for Residents #43, #79, and #91 and stored them in the top drawer of the medication cart. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of their medications as ordered. The findings were: 1. Record review of Resident #43's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities), hypertension (when your blood pressure, the force of blood flowing through your blood vessels, is consistently too high), and Schizoaffective disorder (mental health disorder that is marked by symptoms, such as hallucinations). Record review of Resident #43's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated cognition was moderately impaired. Record review of the Residents #43's Physician monthly order summary for May 2024 revealed, that the following medications were ordered at 9:00 a.m. For Resident #43, Invega for 24 hours, administer one three-mg tab once a day orally for schizoaffective disorder; Losartan 50 mg, administer one tablet orally once a day orally for hypertension; Lyrica, 25 mg capsule, administer one capsule three times a day for pain, Metformin 850 mg tablet administer one tablet once day orally for diabetes Mellitus and Provera 10 mg tab administer three tablets once a day = 30 mg total for inappropriate behaviors. 2. Record review of Resident #79's face sheet, dated 5/5/24, revealed a [AGE] year old -female [AGE] year-old admitted on [DATE] with the diagnosis that included Paranoid schizophrenia (psychosis, which means your mind does not agree with reality), diabetes mellitus (a disease with inadequate control of blood sugar glucose), and Epilepsy (a brain disorder that causes recurring, unprovoked seizures). Record review of Residents #79's Quarterly MDS dated [DATE], revealed the resident had a BIMS of 9, which indicated cognition was moderately impaired. Record review of Residents #79 Physician monthly orders for May 2024 revealed the following medications were ordered at 9:00 a.m., for Resident #79, Gabapentin 300 mg capsule three times a day for polyneuropathy, Valbenazine tosylate tablet administer one tab once a day for tardive dyskinesia, and levetiracetam 500 mg once day seizures. 3. Record review of Resident #91's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted on [DATE] with the diagnosis that included Schizophrenia (involves delusions, hallucinations, 675409 Page 12 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unusual physical behavior, and disorganized thinking and speech), Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and overactive bladder (muscles of the bladder start to tighten on their own even when the amount of urine). Record review of Resident #91's Quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated cognition is intake. Record review of Resident's #91 Physician orders for May 2024 revealed that the following medications were ordered at 9:00 a.m. for Resident #91, Lasix 20 mg administer one tablet by mouth daily for fluid retention. Gabapentin 300 mg, administer one capsule three times a day by mouth for polyneuropathy; Valbenazine tosylate administer one tablet by mouth daily for tardive dyskinesia; and levetiracetam 500 mg, administer one tablet once a day for seizures. Observation and interview with LVN LL on 5/5/54 at 10:30 a.m. revealed medications for Residents #43, #79, and #91 were in the top drawer of the medication cart. LVN LL stated she had written names on medication cups that medications were in and had signed out medication administration record as she had pre-pulled medications for Resident #43, #79 and #91. LVN LL stated medications were not to be poured and signed out as residents may need to be sent out to the hospital and medication administration record may not be accurate. In an interview with the DON on 5/4/24 at 10:45 a.m., the DON stated LVN LL should not have pre-pulled medications for Residents #43, #79, and #91 and stored them on top of the medical cart drawer. The DON stated this deficient practice could lead to medication administration records reflecting incorrect documentation if Residents #43, #79, and #91 were to be sent to the hospital. The DON stated the ADONs monitored nurses at random during the week for storing pre-poured medications in medication carts, and he was overseeing this. Record review of the facility's policy titled, Monitoring of Medication Administration, dated 10/1/19, revealed that medication administration, including frequency, is documented. 675409 Page 13 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

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 1. [NAME] A was did not wear a facial hair restraint while engaged in food preparation and service. 2. There were ten thermometers in the hand-washing sink. 3. In the reach-in cooler there was a 5-lb. bag of Mozzarella cheese past its use-by date and containers of thickened juice and milk without labels indicating a use-by date. 4. [NAME] B wore a wristwatch on his arm while preparing food in the kitchen. 5. The chemical sanitizing solution in the dish machine did not reach the minimum ppm required. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 05/05/2024 at 11:20 AM in the kitchen revealed [NAME] A stood in the the kitchen, covered plates of food that were assembled by dietary aides, and placed the trays on carts. [NAME] A had hair approximately 1/4 in length that covered his upper lip and the chin portion of his face. [NAME] A was not wearing a facial hair restraint. During an interview on 05/05/2024 at 11:21 AM with the [NAME] he stated he knew he should have worn a facial hair restraint, he wore prior to using the restroom and failed to put it back on upon his return to the kitchen. During an interview on 05/05/2024 at 11:22 AM with the FSS she stated [NAME] A had facial hair, was not wearing a facial hair restraint, and knew he should be wearing one. 2. Observation on on 05/05/2024 at 11:23 AM. in the kitchen revealed a two-compartment sink. A sign on the wall above the sink read, Handwashing Sink. In the right compartment there were ten bimetallic stemmed thermometers routinely used to measure food temperatures. The indicator head of one thermometer was inside the drain portion of the sink. During an interview on 05/05/2024 at 11:24 AM with the FSS she confirmed the two-compartment sink was the kitchen's handwashing sink, and indicated the single compartment sink along the left wall was the food preparation sink. The FSS stated the thermometers should not have been in the handwashing sink. 3. Observation on 05/05/2024 at 11:28 a.m. revealed a 5 lb. bag of shredded Mozzarella cheese. The bag was half-full and stored inside a sealed, zipper-locked bag. In the section on the storage bag labeled, Date, 3/16/24 was written in black marker. In the section labeled Use By, 4/30/24 was written in black marker. Further observation in the reach-in cooler revealed: A 46-oz. container of 675409 Page 14 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many thickened orange juice. The container was half-full and did not have a label indicating the date it was opened and a use-by date, and a one-gallon container of whole milk that was half-full and did not have a label indicating the date it was opened and a use-by date. During an interview on 05/05/2024 at 1:15 PM with the FSS she stated the Mozzarella cheese was past its use-by date and should have been discarded, and the thickened juice and milk should have been labeled with use-by dates. It was the responsibility of the cooks and dietary aides to properly label and date food items stored in the coolers and freezers. Staff were trained upon hire and monthly by her and the consultant dietitian. 4. Observation on 05/05/2024 at 11:31 AM in the kitchen revealed [NAME] B mashed potatoes in a pan and scooped stuffing into another pan. [NAME] B wore a wristwatch on his left wrist. During an interview on 05/05/2024 at 11:32 AM with [NAME] B he stated he knew he should not have won a watch during food preparation and forgot to take it off. During an interview on 05/05/2024 at 1:15 PM with the FSS she stated dietary staff were prohibited from wearing jewelry on their hands during food preparation and were trained during orientation. 5. Observation on 05/05/2024 at 11:35 AM in the dish room revealed [NAME] B operated the dish machine. Upon the conclusion of the cycle, [NAME] B dipped a chlorine test strip in the sanitizer solution, waited a few seconds, and compared the color change against the chart provided on the container. Observation of the color of the test strip revealed it closely resembled the color associated with 10 ppm (parts per million). [NAME] B ran the dish machine again and upon conclusion of the cycle another test strip was used. This test strip also indicated the concentration of chlorine in the sanitation solution was 10 ppm. During an interview on 05/05/2024 at 11:35 AM [NAME] B stated the concentration of chlorine was inadequate and he would contact the service provider of the machine. During an interview on 05/07/2024 at 11:09 AM with the FSS she stated the reason the test strips used on 05/05/2024 indicated the concentration of chlorine in the machine was below the minimum required level of 50 ppm was because the strips were expired, and she had since procured a new container of test strips. Observation on 05/07/2024 at 11:15 AM in the dish room revealed the FSS ran the dish machine, a test strip was used from the new container, and the color of the test strip indicated the level of chlorine in the sanitizer solution was in the 10 ppm range. Record review of facility policy 04.001 Employee Sanitation approved 10/01/2018 revealed, 3. Employee Cleanliness Requirements: b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. f. No jewelry can be worn on the arms and hands while preparing food except for a single plain ring such as a wedding band. Record review of facility policy 04.002 Hand Washing approved 10/01/2018 revealed, Procedure: 1. Hand-washing Stations. d. Sinks used for food preparation or washing utensils or a service sink .cannot be used as a hand-washing station. Review of facility policy 04.006, Food Storage, Revised 06/01/2019, revealed, Policy: To ensure 675409 Page 15 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of facility policy 04.006 Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 2. Make sure that the automatic detergent dispenser and/or liquid sanitizer injector is working properly. 7. If a machine that uses f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used. A sample Dish Machine Temperature and Sanitizing Log follows this policy. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-301.15, revealed, Where to Wash. Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of product storage instructions from the manufacturer of the thickened orange juice, water and sweet tea revealed all three products had the same storage instructions: Refrigerate after opening and use within 7 days. https://lyonsreadycare.com/collections/dysphagia/products/thickened-orange-juice-cartons-nectar-level-2. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2012, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of 675409 Page 16 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many H&HS, revealed: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart: Concentration Minimum Minimum Range Temperature Temperature mg/L pH 10 or Less pH 8 or Less 25-49 120 degrees F 120 degrees F 50-99 100 degrees F 75 degrees F 675409 Page 17 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

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 observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #29) reviewed for infection control, in that: Residents Affected - Few CNA E did not change her gloves or wash her hands after providing incontinent care for Resident #29 These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #29's face sheet, dated 05/07/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/25/2021, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (Under active Thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Liver disease (loss of liver function), Chronic kidney disease (Gradual loss of kidney function), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #29's Quarterly MDS assessment, dated 02/23/2024, revealed Resident #29 has a BIMS score of 4, which indicated severe cognitive impairment. Resident #29 was indicated to frequently be incontinent of bowel and bladder. Record review of Resident #29's Optional State assessment dated [DATE] revealed Resident #29 required extensive assistance with his activities of daily living. Review of Resident #29's care plan, dated 07/02/2021, revealed a problem of The resident has potential skin integrity related to Debility as evidence by decreased bed mobility, incontinent of bowel and bladder habits, History of cellulitis to Right forearm, with a goal of of The resident will maintain or develop clean and intact skin by the review date. Observation on 05/07/24 at 10:06 a.m. revealed, while providing incontinent care for Resident #29, CNA E did not change her gloves or wash her hands after providing incontinent care for Resident #29 and before touching and fastening the clean brief to Resident #29. During an interview on 05/07/2024 at 10:20 a.m. CNA E confirmed she did not change her gloves or wash her hands prior to touch the clean brief. She confirmed she received infection control training with the year. During an interview with the DON on 05/07/2024 at 1:30 p.m., the DON confirmed gloves must be changed after cleaning and before touching clean brief to prevent cross contamination. The DON revealed the ADONs were the ones training the staff for infection control and that they would check the staff skills annually and as needed if a problem was noted. 675409 Page 18 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of facility policy, titled Perineal care, dated 10/24/2022, revealed [ .] clean and dry the bottom of the scrotum and the anal area. If using soap, rinse after washing. apply skin protectant as needed [ .] remove gloves and discard. Perform hand hygiene. Residents Affected - Few 675409 Page 19 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

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 observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 5 resident hallways reviewed for environmental conditions ensure in that: The facility failed to ensure four resident hallways did not have hallway side rails that were not clean and sticky to the physical touch. This deficient practice could place residents at risk of living in an unsanitary environment. The findings included: Observation on 5/5/24 from 10:15a.m.,to 10:40 a.m., on the resident 500 hallway revealed that the hallway side rails on both sides of the hallway appeared to be unclean with a noticeable sticky touch to the side rails. The motion of leaning up against the siderails caused the Surveyor-L's pants to stick to the side rail in multiple locations on the hallway. Observation on 5/8/24 from 1:00pm to 1:20 pm with the Housekeeping Director revealed the following: a-the side rail outside of room [ROOM NUMBER] appeared unclean with a sticky touch to the surface. b-the side rails on both sides of resident hallway 200 appeared unclean with a sticky touch to the surface. c-the side rail outside of room [ROOM NUMBER] appeared unclean with a sticky touch to the surface. During an interview with the Housekeeping Director on 5/8/24 at 1:25 p.m., he stated that housekeepers were assigned to regularly clean the resident hallways and would wipe off an identified sticky portion of the siderail when it was reported to them. The Housekeeping Director stated that he completed daily monitoring of the housekeepers cleaning assignments. During an interview on 5/8/24 at 1:45 p.m., the Administrator stated that he felt the facility resident hall handrails were cleaned all the time. The Administrator stated that having clean resident hall handrails was important for the cleanliness of the facility. Record review of the facility's Environmental Services Policies and Procedures Manual that was undated stated that the facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. 675409 Page 20 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

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 Based on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 1 building reviewed for pest control. Residents Affected - Some The facility did not have an effective pest control program to eradicate the flies in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns. Findings included: Observation on 05/05/2024 at 10:57 a.m. revealed one fly landed on a laptop while on hall 300 Observation on 05/05/2024 at 11:14 a.m. revealed a fly landing on a person on 400 hall. Record review of Resident #33's face sheet, dated 05/08/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/27/2024 with diagnoses which included: Dementia (decline in cognitive abilities), Hemiplegia(Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure) and, Chronic kidney disease (gradual loss of kidney function). Record review of Resident #33's Quarterly MDS assessment, dated 03/20/2024, revealed a BIMS score of 99 with memory problem and modified independence. Observation on 05/07/2024 at 11:00 a.m., during administration of Insulin to Resident #33, revealed there were 3 flies were noted on the bed of Resident #33. In an interview with Resident #33 on 05/07/2024 at 11:02 a.m., Resident #33 revealed the flies were his friends that carry messages for him. In an interview with LVN G on 05/07/2024 at 11:05 a.m., LVN G stated the facility had flies and they probably entered when people went in and out of the facility from smoking. In an interview with LVN H on 05/07/24 at 11:10 a.m., LVN H confirmed there were flies in the facility. LVN H stated the number of flies used to be worse but they were still around. LVN H stated she thought the flies entered by the back door and there were nothing on top of the door to keep them from entering. Observation on 05/07/2024 at 11:25 a.m., during lunch service, revealed a couple of flies were seen around residents when they were eating. No resident verbally complained about them when asked but they were swatting at them Observation on 05/08/2024 at 9:10 a.m. revealed there were flies in the social worker office. The Social Worker did not comment on the presence of the flies. Observation on 05/07/2024 at 2:00 p.m. revealed there were flies in the dishwashing room and in the sink area of the kitchen. 675409 Page 21 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of contracts revealed the facility had a contract with a professional company for pest control, and they were contracted to come monthly and as needed if called Record Review of the sighting log revealed on 4/16/2024 and 04/29/2024 flies were sighted in the facility. Record review of service log form revealed the pest control company did a visit on 4/29/2024 but treated the facility for fire ants not flies. Further review of the log revealed the pest control company treated for flies on 4/4/2024. During an interview on 05/08/2024 at 10:50 a.m., the Administrator confirmed the presence of flies in the facility. The Administrator state the facility's plan was to increase the number of visit from the pest control company and to treat for flies every time. The Administrator confirmed the pest control company was coming monthly and also as needed if the staff was reporting pest in the sighting log. 675409 Page 22 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 4 of 22 staff (CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist) reviewed for training requirements in that: The facility failed to ensure four staff which included: CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist received the required training on resident rights during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the undated facility staff list revealed that CNA N was hired on 7/8/93, the Food Service Director was hired on 8/10/2005, the Physical Therapist was hired on 2/16/2015, and the Speech Therapist was hired on 2/1/2012. During an interview with the Director of Human Resources on 5/7/2024 at 1:00 p.m. she stated that there was not documentation that CNA N, the Food Service Director, the Physical Therapist, or the Speech Therapist received Resident Rights training in 2023. The Director of Human Resources stated she felt the Department Heads, the Human Resources Director, the Administrator, and the employee themselves were all responsible for ensuring the required education was completed. The Human Resources Director stated completion of the Resident Rights training would help the staff to be better educated when providing resident care. The Human Resources Director stated that the facility did not have a policy on the need for employees to complete their required in-service training. During an interview with the Administrator on 5/7/2024 at 4:00 p.m., the Administratir stated employees needed to complete their required training. The Administrator stated completing their required in-service training would help their overall provision of resident care. 675409 Page 23 of 24 675409 05/08/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to ensure the staff members were educated on abuse, neglect, and exploitation related to resident care for 5 (CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist) of 22 staff reviewed for training requirements in that: The facility failed to ensure that five staff which included: CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist received the required training on abuse/neglect/exploitation during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the undated facility staff list revealed that CNA F was hired on 4/19/2019, the Food Service Director was hired on 8/10/05, LVN G was hired on 7/14/08, the Occupation Therapist was hired on 4/3/23, and the Speech Therapist was hired on 2/1/2012. During an interview with the Director of Human Resources on 5/7/2024 at 1:00 p.m. she stated that there was not documentation that CNA UU, the Food Service Director, LVN TT, the Occupational Therapist, or the Speech Therapist received Abuse/Neglect/Exploitation training in 2023. She stated she felt the Department Heads, the Human Resources Director, the Administrator, and the employee themselves were all responsible for ensuring the required education was completed. The Human Resources Director stated completion of the abuse/neglect/exploitation training would help the staff to be better educated when providing resident care. The Human Resources Director stated that the facility did not have a policy on the need for employees to complete their required in-service training. During an interview with the Administrator on 5/7/2024 at 4:00 p.m., he stated that employees needed to complete their required in-service training. The Administrator stated that completing their required in-service training would help their overall provision of resident care. 675409 Page 24 of 24