Health inspection·July 26, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 4 of 23 residents (Residents #43, #48, #45, and #31) reviewed for a safe, clean, and comfortable environment, in that: 1. Resident #43's bathroom floor molding which measured approximately 1.5 feet by 4 inches was removed from the wall. 2. Resident #48's bathroom ceiling vent which measured approximately 6x4 inches was rusty and covered with dirt particles. 3. Resident #45's bathroom ceiling vent which measured approximately 6x4 inches and the bedroom ceiling vent which measured approximately 1.5 feet by 4 inches were covered with dust and dirt particles. 4. Resident #31's toilet was running and would not stop on it's own. These deficient practices could lead to diminished quality of life and psychosocial harm. The findings were: 1. Observation of Resident #43's bathroom on 07/23/24 at 10:15 a.m. revealed that the bathroom floor molding which measured approximately 1.5 feet by 4 inches was detached from the bathroom wall. 2. Observation of Resident #48's bathroom on 7/23/24 at 10:50 a.m. revealed the bathroom ceiling vent which measured approximately 6 x 4 inches had rust and dirt particles on the vents. 3. Observation of Resident #45's bathroom on 7/23/24 at 10:55 a.m. revealed a ceiling vent which measured approximately 6 x 4 inches that contained dust and dirt particles. There was also a ceiling vent in the bedroom area over the closet which measured approximately 1.5 feet by 6 inches that contained dust and dirt particles. 4. Observation of Resident #31's bathroom on 7/26/24 at 10:30 a.m. revealed the bathroom toilet ran continuously and would not shut off. Observation with the Administrator on 7/26/24 at 10:45 a.m., the Administrator observed the bathrooms for Residents' #43, #48, #45, and #31 with the areas needing repair. Page 1 of 10 675446 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0584 Level of Harm - Minimal harm or potential for actual harm During an interview with the Administrator on 7/26/24 at 10:50 a.m., the Administrator stated a new facility Maintenance Director had just begun employment several days ago. The Administrator stated the maintenance position had been vacant for over one month. The Administrator confirmed that repairing the bathroom areas for Residents' #43, #48, #45, and #31 would promote a more homelike environment for them. The Administrator stated she was not aware of the problems in the residents' bathroom. Residents Affected - Some Record review of the facility's policy titled, Homelike Environment, dated 2021, revealed, residents are to be provided with a safe, clean, comfortable, and homelike environment. 675446 Page 2 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 the residents (Residents #16 and #37) reviewed for respiratory care, in that: Residents Affected - Few The nebulizer tubing of Residents #16 and #37 was on their bedside tables unbagged and undated. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: 1. Record review of Resident #16's face sheet, dated 7/23/24, revealed a 74-year male admitted to the facility on [DATE] with the diagnoses that included Spina bifida (a birth defect in which there is incomplete closing of the spine and the membranes around the spinal cord), Asthma (is a chronic lung disease that causes the airways in the lungs to become inflamed and narrowed), and medical condition in which the bones become brittle and fragile from loss of tissue. Record review of Resident #16 Quarterly MDS, dated [DATE], revealed a BIMS of 13, which indicated intact cognition. Record review of Resident #16's Physician monthly orders dated July 2024 revealed an order start date of 10/19/24: Ipratropium-Albuterol Solution for nebulization 0.5 mg -3 mg every 6 hours as needed. Observation on 7/23/24 at 9:35 a.m. revealed that Resident #16's nebulizer tubing was unbagged, undated, and on the bedside table. During an interview with Resident #16 on 7/23/24 at 10:44 a.m., the resident stated they did not bag the nebulizer tubing at the facility. 2. Record review of Resident #37 face sheet, dated 7/23/24, revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included Atrial fibrillation (a common type of irregular heartbeat, or arrhythmia, that causes the heart to beat faster and irregularly), Major Depression (a severe mood disorder that can affect how a person feels, thinks, and behaves) and Heart Failure( a severe condition that occurs when the heart can't pump enough blood and oxygen to meet the body's needs). Record review of Resident #37 Quarterly MDS, dated [DATE], revealed a BIMS of 15 which indicated intact cognition. Record review of Resident #37's Physician's monthly orders dated July 2024 revealed an order start date of 4/08/24: Ipratropium-Albuterol Solution for nebulization 0.5 mg -3 mg administer one vial at bedtime. Observation on 7/23/24 at 10:35 a.m. revealed Resident #37's nebulizer tubing was unbagged, undated, and on the bedside table. 675446 Page 3 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident #37 on 7/23/24 11:20 a.m., the resident stated she did not know if they had bagged the nebulizer tubing. During an interview with LVN A on 7/23/24, at 11:33 a.m., LVN A stated she was the assigned LVN to Residents #16 and #37. LVN A stated the night shift changed nebulizer tubing weekly and bagged them, however, she did not know why the nebulizer tubing for Residents #16 and #37 were not being bagged and dated. LVN A stated residents were at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. During an interview with the DON on 7/24/24 at 9:05 a.m., the DON stated Residents #16 and #37 should have had their nebulizer tubing bagged and dated by the night shift. The DON stated she did not know why the nebulizer tubing was not bagged and dated for Residents #16 and #37. the DON also stated the ADON oversaw the task and assured that she would be monitoring it for compliance. The DON emphasized that Residents #16 and #37 were at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. Record review of the facility's policy titled, Administering Medications Through a Volume Handheld, dated 2001 revised October 2010, revealed, Change equipment every 7 days or according to facility protocol. 675446 Page 4 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **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 1 of 5 residents (Resident #16) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #16's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered. The findings were: Record review of Resident #16's face sheet, dated 7/23/24, revealed a 74-year male admitted to the facility on [DATE] with the diagnoses that included Spina bifida (a birth defect in which there is incomplete closing of the spine and the membranes around the spinal cord), Asthma (is a chronic lung disease that causes the airways in the lungs to become inflamed and narrowed), and medical condition in which the bones become brittle and fragile from loss of tissue. Record review of Resident #16's Quarterly MDS, dated [DATE], revealed a BIMS of 13, which indicated intact cognition. Record review of Resident #16's Patient medication summary for July 2024 revealed an order for an albuterol sulfate inhaler, Administer two puffs every four hours as needed for shortness of breath. Further review revealed an order for Resident # 16 to self-administer medication was not found in the monthly order summary for July 2024. Record review of Resident #16's care plan, dated 3/14/24, did not reveal a care plan to address Resident #16 self-administered own medication. Observation on 7/23/24 at 9:10 a.m. revealed an albuterol Sulfate inhaler on Resident #16's bedside table. During an interview with Resident #16 on 7/23/24 at 9:20 a.m., the resident stated he used albuterol sulfate inhaler whenever needed as he did not like to bother his nurses. During an interview with LVN A on 7/23/24 at 10:30 a.m., LVN A stated she was the assigned nurse for Resident #16 and was unaware that an albuterol sulfate inhaler should not be at the resident's bedside table. LVN A stated Resident #16 risked over-using his albuterol sulfate inhaler if it was left at bedside . LVN A stated Resident #16 did not have an order to self administer medications. During an interview with the DON on 07/24/24 at 2:15 p.m., the DON stated Resident #16 should not have any medication at bed side. The DON also stated Resident #16 might self-administer more medication than was ordered by the physician. The DON stated she currently had the ADON monitoring medications at the bedside weekly, and she oversaw the task monthly. Record review of the facility's policy titled, Medication Administration, dated 7/8/24, revealed, 675446 Page 5 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0761 Residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675446 Page 6 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements, in that: The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the employee personnel file provided by the facility revealed the hire date for the DM was 10/20/2023. Further review of the personnel file, which included the DM's resume, revealed no documented evidence the DM was: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality; or (E) Had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Record review of facility employee files revealed the facility's RD was contracted and was not a full-time employee of the facility. During an interview on 07/23/2024 at 11:00 AM, the DM stated she was hired by the facility in late 2023, she had previously worked for the school district, she was not a certified dietary manager or certified food service manager and was not presently enrolled in a program to become certified. During an interview on 07/26/2024 at 12:20 PM, the HR Director stated the DM was hired on 10/20/2023, and was not a certified dietary manager and was not enrolled in a course of study at that time. During an interview on 07/26/2024 with the Administrator she stated she understood the DM was not a certified dietary manager or certified food service manager. The Administrator stated she believed the DM had a year from her hire date to complete a program to become certified, and she also thought the DM was enrolled in a program to become certified. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified 675446 Page 7 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12. 675446 Page 8 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 reviewed for kitchen sanitation, in that: 1. There was a bag of strawberries in the reach-in freezer without a label indicating a use-by date. 2. There was a loaf of bread in the dry storage room past its use-by date. 3. There were three packages of tortillas in the dry storage room past their use-by date. 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 07/23/2024 at 10:17 AM inside the reach-in freezer revealed a gallon-sized zip-locked bag of frozen strawberries. There was no marking on the bag indicating the storage or use-by date. 2. Observation on 07/23/2024 at 10:19 AM in the dry storage room revealed one unopened loaf of wheat bread with a facility date of 7/10 on the wrapper. The best by date on the wrapper was [DATE]. 3. Observation on 07/23/2024 at 10:21 AM in the dry storage area revealed three packages of burrito-sized tortillas. Two bags (10 each) were unopened; one bag had been opened and there were 5 tortillas loosely wrapped with plastic wrap. All three bags had a facility date of 6/28 and were labeled best by [DATE] on the wrappers. During an interview on 07/23/2024 at 11:00 AM, the DM stated the strawberries had recently been used and stored but should have been properly labeled and dated with the use-by date by the cook or dietary aide who returned them to the freezer. The DM stated the loaf of bread and tortillas should have been discarded by the date marked by the facility. The DM routinely checked to ensure proper rotation of the product but missed these items. The DM trained dietary staff monthly on food safety and sanitation procedures. Record review of facility policy Refrigerators and Freezers, October 2022, revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. 675446 Page 9 of 10 675446 07/26/2024 Prairie Meadows Rehabilitation and Healthcare Cent 1615 Eleventh St Floresville, TX 78114

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of facility policy, Dry Storage, Reviewed January 2023, revealed, DRY STORAGE. 3. All items must be dated with the date that the food was delivered. 5. All expired foods must be removed from the store room. 7. Food is dated so that the food that the food that is delivered first can be used first. This is called Fl FO-First in first out. 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. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: Annex 4. Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors. Annex 4 - 6 First-In-First-Out (FIFO) procedures. 4. Establish First-In-First-Out (FIFO) Procedures. Product rotation is important for both quality and safety reasons. First-In-First-Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. 675446 Page 10 of 10