Health inspection·July 21, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in one of four medication carts for expired medications. The facility failed to ensure expired medications were removed from stock in one out of four medication carts. This failure could place residents at risk of not receiving the intended therapeutic benefit of their medications. Findings included: Observation on 07/20/22 at 10:24 a.m. of the 200-hallway medication cart revealed, a bottle of Aspirin 325 mg tablet with an expiration date of 6/22. This bottle was found in the 200-hall medication cart which means this medication was not for a specific resident. Interview on 07/20/22 at 10: 24 a.m . with RN A revealed, it is my responsibility to remove expired medications. She stated, I just missed it. I am sorry. Anyone could have received this medication in the 200 hallway that had an order for Aspirin 325mg tablet. RN A stated that giving expired medications can decrease its effectiveness. Interview on 07/21/22 08:58 a.m. with the DON revealed that he stated I go through medications every Sunday. He stated she got specialized glasses a week ago and maybe that was what caused her to miss that expired medication. DON stated that giving expired medications can decrease potency. Review of the facility's policy on Medication Storage in the Facility dated January 2018, revealed, . G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining . Page 1 of 8 675550 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident the most recent hospice plan of care specific to each patient, the physician certification and recertification of the terminal illness specific to each patient, hospice election form and hospice medication information specific to each patient for two (Residents #15 and #79) of three residents reviewed for hospice services. The facility failed to obtain the most recent hospice plan of care, the physician certification and recertification of the terminal illness, hospice election form and hospice medication information from Hospice M for Resident #15 and Hospice N for Resident #79. This failure could result in services and treatments for end-of-life care not being properly coordinated. Findings included: 1. Record Review of Resident #15's face sheet dated 07/20/22 reflected Resident #15 was admitted to the facility on [DATE] with diagnoses of liver failure, low back pain, dysphagia and heart failure . She was receiving hospice services through Hospice. Record Review of Resident #15's Annual MDS assessment dated [DATE] reflected she had a BIMS of 15 indicating she was cognitively intact. She was on hospice services while at the facility. Record Review of Resident #15's Comprehensive Care Plan, last revised on 07/19/22, reflected the date initiated for hospice services was on 11/17/20with Hospice M due to hepatic failure. Record Review of Resident #15's electronic clinical record revealed no hospice documentation for Resident #15. Interview on 07/19/22 at 10:19 AM with Resident #15 revealed she was on hospice services with Hospice M and the hospice aide came to facility three times a week to bathe her. Interview on 07/20/22 at 10:18 AM with the DON revealed he could not locate Resident #15's hospice book and stated they do not scan hospice documentation into the electronic record. He stated he did not know where any of Hospice M's books were at that time for the hospice residents. In a follow up interview on 07/20/22 at 12:55 PM with the DON revealed they could not find any hospice documentation from Hospice M on Resident #15. He stated Hospice M was contacted today after being unable to find hospice documentation for Resident #15 and state the nurse will bring it today. He was not aware of what required hospice documentation the facility needed for hospice residents. He stated they should have a hospice binder for each resident which should include the required hospice documentation. Hospice is in charge of ensuring required hospice documentation is on file. Interview on 07/20/22 at 2:32 PM with Hospice RN G revealed she has not been providing the facility with up-to-date hospice documentation on residents including Resident #15. She stated she took 675550 Page 2 of 8 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hospice M binders for her patients with her last week but did not tell anyone at the facility. She stated the hospice binders were not up-to-date until today and she had gotten behind in making sure facility had required hospice documentation. She stated the facility had not discussed hospice documentation with her. 2. Record Review of Resident #79's face sheet dated 07/20/22 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of local infection of the skin, Alzheimer's disease, dysphagia, hypertension. Review of Resident #79's Significant change MDS assessment dated [DATE] reflected she had a BIMS of 5 indicating she was severely cognitively impaired. She was on hospice services while in the facility. Review of Resident #79's current physician orders dated 06/25/22 reflected Resident #79 was admitted to Hospice N for diagnosis of Alzheimer's disease. Interview on 07/20/22 at 10:18 AM with the DON revealed he could not locate Resident #79's hospice book and stated they did not scan hospice documentation into the electronic record. In a follow up interview on 07/20/22 at 12:55 PM with the DON revealed the facility requested Hospice N's documentation for Resident #79 after not being able to find any on file. He was not aware of what was the required documentation the facility needed for residents on hospice services. Review of facility's policy Hospice Program undated reflected 3. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family should be developed and should include directives for managing pain and other uncomfortable symptoms. The policy did not reflect other required hospice documentation. 675550 Page 3 of 8 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

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 ensure all patient care equipment was in safe operating condition for 2 (Residents #48 and #63) of 15 residents reviewed for wheelchair maintenance. Residents Affected - Some The facility failed to properly maintain wheelchairs for Residents#48 and #63. This failure placed residents by placing them at risk for skin tears and discomfort. Findings included: An observation of Resident #48's wheelchair on 07/19/22 9:30 am revealed both armrest vinyl pads were cracked with the foam exposed. The left pad wrapped with clear tape and the forward 1/3 of the armrest and the back half of the pad could be lifted from the armrest. In an interview on 07/19/22 at 9:30 am with Resident #48, he stated the armrest had been like this a while and he would like for it to be repaired. He had already told the nurse before. On 07/20/22 at 9:40 am observed Resident#63's wheelchair which had the right armrest missing and the left armrest vinyl is cracked with the foam beneath exposed. In an interview on 07/20/22 at 12:15 pm, the Maintenance Director stated if a wheelchair needed repair, the staff let him know by the TELS systems which comes directly to his phone, and he repaired the wheelchair. He stated he was not aware of wheelchairs that needed repair. In an interview on 07/20/22 at 12:28 pm with the Administrator , he stated if a wheelchair needed repair, the staff let maintenance know by entering it into the TELS systems which went to the Maintenance Director's personal cell phone to let maintenance know of the needed repairs. In an interview on 07/20/22 at 12:35 pm , LVN B stated if a wheelchair needed repair, the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair. In an interview on 07/20/22 at 12:37 pm with LVN C stated if a wheelchair needed repair the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair. In an interview on 07/21/22 at 8:30 am with CNA D stated when a wheelchair needed repair the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair. In an interview on 07/21/22 at 8:35 am with CNA E when a wheelchair needed repair the staff let the maintenance know by entering it into the TELS systems which goes to the maintenance personal cell phone to let maintenance know of the needed repair. A review of May, June, and July 2022 revealed the messages sent through the TELS system to the maintenance department, reflected none had been for repair of residents' wheelchairs. 675550 Page 4 of 8 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

F 0908 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy entitled, 'Maintenance Service, dated 2002 , indicated The Maintenance Department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times. Residents Affected - Some 675550 Page 5 of 8 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

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, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents reviewed for pest control. Residents Affected - Some The facility failed to keep an effective pest control program to ensure resident dining rooms, facility kitchen and resident rooms were free of gnats and flies. This failure could place residents at risk for a reduced quality of life. Findings include: Observation on 07/19/22 at 9:25 AM revealed two flying insects in facility's kitchen preparation on steamtable. Observation and Interview on 07/19/22 at 9:40 AM with Resident #7, in her room, revealed the facility had flies and stated she has been told they can't use bug spray and won't find her a fly swatter. Observation of two flies and one gnat was made in her room, One fly and one gnat were observed in the window sill. She tells anyone who comes into her room about it and they say they can't use bug spray at the facility. She asked for fly swatter from staff, but they leave and don't hear from them again. Observations on 07/19/22 during lunch time: - At 12:09 PM, Resident #60 had a fly lay on his water glass. - At 12:11 PM, A facility staff member swatted a fly away from Resident #62's food with her hand. - At 12:16 PM, Resident #56 had a fly land on her coffee mug and she swatted it away with her hand. - At12:17 PM Resident #80 had a fly land on his hand while he was eating his lunch. Observation on 07/19/22 at 12:15 PM revealed Administrator gave LVN C a fly swatter while in the dining room to take care of the flies. Observation and interview on 07/19/22 at 12:22 PM revealed Resident # 49 had a flying insect landing on her lunch plate. Resident #49 swatted it away. Resident #49 on 12:26 PM stated the flies were bothering her today, especially during meal times when she was eating. She was observed swatting at a fly. Interview on 07/20/22 at 8:50 AM with Resident # 80 revealed he saw flies in the dining room a long time during meal times, as regular occurrence. Observation on 07/20/22 at 2:09 PM in facility kitchen revealed two flies. One landed on the steam table and the other one landed on the stove. Interview on 07/20/22 at 2:10 PM with Dietary Aide O revealed she noticed flies in the kitchen 675550 Page 6 of 8 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

F 0925 recently especially when people enter from the outside door the flies come in. Level of Harm - Minimal harm or potential for actual harm During a resident confidential group interview with 11 residents, all 11 residents stated they have flies and gnats in their facility and see them everywhere for a long time. They stated it started with gnats and then it had gotten worse with the larger flies. They stated at that time, the facility had both. Residents Affected - Some Interview on 07/20/22 at 9:10 AM with LVN F revealed the facility did have an issue with pests including flies and gnats especially in the dining rooms during meal times. She stated the flies have been in the facility for at least a few weeks and it started with the smaller flies (gnats). She stated the facility treated the smaller flies but then the regular flies started showing up. Interview on 07/21/22 at 9:08 AM with the Maintenance Director revealed pest control came out and treated pests. He was not sure when; prior to yesterday, the facility treated flies . He stated they came out recently to treat for ants. Interview on 07/21/22 at 9:10 AM with Administrator revealed pest control came out twice a month and yesterday they came out due to the flies. He stated they treated the drains in the kitchen. They have ordered fly traps as of yesterday but were not aware could have these before yesterday. They will come back the 07/26/22 to treat drains again and it will be regular. He stated going forward from now on each time pest control comes out to facility they will treat the drains in the kitchen where the flies are coming in from. Interview on 07/21/22 at 9:30 AM with Dietary Manager revealed she had noticed flies in kitchen and dining room recently. Record Review of facility's Pest Control Log from April to July 2022 did not reflect any flies or gnats. Review of May to July 2022 pest control visits reflected the following: -Dated 05/16/22 reflected pest control inspected and treated in these areas; interior and exterior restrooms, kitchen area, dining area, treated hallway 300 and exterior serviced all devices . Target pests treated were drain flies/fruit flies/vinegar flies, house flies. -Dated 06/10/22 reflected pest control inspected and treated kitchen. Pest control granulated building for ants. -Dated 06/28/22 reflected pest control inspected and treated interior and exterior restrooms, kitchen area, hallways and serviced bait boxes for rodent control. Targeted pests were rodents and crawling insects. There was no treatment completed for flies or gnats. -Dated 07/14/22 reflected pest control inspected and treated interior and exterior hallways, office, kitchen area, dining area rooms and exterior windows. There was no treatment completed for flies or gnats. -Dated 07/20/22 reflected pest control treated interior for flies and drain flies. It reflected invade foam application to help control the drain flies and that included kitchen, showers, laundry room and sprayed exterior dining room . Pest control hung up 3 fly glue traps in the dining area and 675550 Page 7 of 8 675550 07/21/2022 Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

F 0925 recommended fly lights in ever hallway to control the situation. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy Pest Control, revised May 2008, reflected the facility should maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Maintenance serves assist , when appropriate and necessary, in providing pest control services. Residents Affected - Some 675550 Page 8 of 8