Health inspection·November 2, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and stomach ulcers for 1 of 1 resident fed by gastrostomy tube (g-tube) (Resident #57), in that: The facility failed to ensure LVN C administered medication by gravity, he pushed them in via g-tube. This failure could result in residents aspirating (inhaling into airway) gastric contents and/or stomach ulcers in residents with a g-tube. The findings include: Review of Resident #57's Quarterly MDS assessment dated [DATE] reflected Resident #57 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebrovascular accident (damage to the brain from interruption of its blood supply), dysphagia (A condition that affects the ability to produce and understand spoken language), and feeding tube. Resident #57's BIMS was 10, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #35 required extensive assistance of one-person physical assistance with transfer, and personal hygiene. Record review of the current care plan for Resident #57, dated 10/31/23, revealed focus: Resident#57 NPO and requires tube feeding r/t Swallowing problem. Goal: Resident #57 will be free of aspiration. Record review of the order summary report for Resident #57, dated 11/01/23, revealed orders for: - NPO diet related to DYSPHAGIA FOLLOWING CEREBRAL INFARCTION (cerebrovascular accident) - Aspirin tablet chewable 81 MG. Give 1 tablet via G-Tube (tube feeding) one time a day for heart health. - Amlodipine besylate tablet 10 MG. Give 1 tablet via G-Tube two times a day for elevated blood pressure, give only when systolic blood pressure was greater than 130.? - Carvedilol tablet 25 MG. Give 1 tablet via G-Tube two times a day related to hypertensive heart disease. Page 1 of 7 675702 675702 11/02/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Polyethylene Glycol 3350 oral powder 17 GM/SCOOP (Polyethylene Glycol 3350). Give 1 scoop via G-Tube in the morning for Constipation. Mix completely with water and give via G-tube. Hold for diarrhea or loose stools. Observation on 11/01/23 at 8:00 AM, revealed LVN C began to administer morning medications to Resident #57 via G-tube. LVN C began by flushing the g-tube with 30mL of water via push, not by gravity. LVN C then diluted the first medication with water and pushed the medication into the g-tube. LVN C then flushed the G-tube with 10mL of water via gravity. LVN C administered all morning medications by push, not gravity. Interview on 11/01/23 at 8:45 AM, LVN C stated he normally administered Resident #57's medications via gravity, not by pushing them in. LVN C stated the G-tube clogged that was why he pushed the medications. LVN C stated he had been trained to administered G-tube medications via gravity. LVN C stated the potential negative outcome to the resident could be discomfort. Interview on 11/02/23 at 8:52 AM, the DON stated he expected the nurses to administer medications to residents with a G-tube via gravity. The DON stated the facility had provided G-tube care education, but he did not have any specific competencies for G-tube medication administration for LVN C. The DON stated the potential negative outcome to the resident would be pushing in a lot of air, and discomfort to the resident. Record review of facility policy, titled, Enteral Tube Medication Administration, dated August 2020 reflected the following: Procedures: . 15. Remove the plunger from the 60 ml syringe and connect the syringe to the clamped tubing using the appropriate port b. Pour dissolved medication in the syringe and unclamp tubing, allowing medication to flow by gravity . 675702 Page 2 of 7 675702 11/02/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 each resident for 2(Nurses Cart halls 100/200 and Med Aide cart halls 400/500) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN A, responsible for Nurses cart halls 100/200, counted controlled drugs every shift change and removed medications in unsecure containers from the Nurses Cart. 2- MA B responsible for Med Aide cart halls 400/500, counted controlled drugs every shift change. Thes failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1- Record review and observation on 10/31/23 at 9:58 AM of Nurses Cart halls 100/200, with LVN A revealed: - missing signatures for Off duty and On duty for 10/04/2023, 10/10/2023, 10/22/2023 of the narcotic count sheet. - The blister pack for Resident #88's acetaminophen-codeine 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. - The blister pack for Resident #3's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister and tapped over. Interview on 10/31/23 at 10:01 AM, LVN A stated nurses and medication aides should have signed the narcotic sheet after counting the narcotics on 10/04/2023, 10/10/2023, and 10/22/2023. LVN A stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk of not signing the narcotic sheets and a damaged blister would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blister during the count. She stated when a broken seal was observed, two nurses should discard the medication. Interview on 11/02/23 at 12:36 PM, LVN D stated she should have signed the narcotic sheet before and after counting the narcotics on 10/04/2023, 10/10/2023, and 10/22/23. LVN D stated, I counted the narcotics but forgot to sign. LVN D stated this failure could potentially cause a drug diversion. 2- Record review and observation on 10/31/23 at 10:32 AM of Med Aide Cart halls 400/500, with MA B revealed missing signatures for Off duty and On duty for 09/13/2023, 09/14/2023, 09/26/2023 of the narcotic count sheet. 675702 Page 3 of 7 675702 11/02/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/31/2023 at 10:32 AM, MA B stated nurses and medication aides should have signed the narcotic sheet after counting the narcotics on 09/13/2023, 09/14/2023, and 09/26/2023. Interivew on 11/02/23 at 12:46 PM LVN E, was not successful. Interview on 11/02/23 at 8:52 AM, the DON stated he expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, he was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken and would be infection control issue. He stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the cart randomly. Review of the facility's policy Storage of Medications dated September 2018, reflected the following: . 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists 675702 Page 4 of 7 675702 11/02/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (100/200 hall Nurse Medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure the 100/200 Hall Nurse Medication cart did not have an expired Assure Dose Control Solution. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: Observation on [DATE] at 9:58 AM of hall 100/200 Nurse cart with LVN A revealed an expired blood glucose control solution (used to calibrate the glucometers). The blood glucose control solution opened and expired [DATE]. Interview on [DATE] at 10:01 AM, LVN A stated she had not seen the expired blood glucose control solutions and would have removed it immediately. She stated she used the blood glucose control solution this morning. She stated the risk would be to get a wrong reading of blood sugar. Interview on [DATE] at 8:52 AM, the DON stated nurses had to check for expired blood glucose control solutions on their carts daily. He stated the risk of using expired blood glucose control solutions would be potential for inaccurate reading and inaccurate treatment. He stated all nurses were responsible to check the medication carts and the medication room for expiration and labeling of medication and solutions. Review of the facility's policy Storage of Medications dated [DATE], reflected the following: . III. Expiration Dating: . 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency . 675702 Page 5 of 7 675702 11/02/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

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 observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. Residents Affected - Some 1. The facility failed to discard food stored in the refrigerator that should no longer be consumed. 2. The facility failed to discard food stored in the dry storage that should no longer be consumed. 3. The facility failed to ensure staff are only using clean utensils when accessing bulk foods. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation in facility's kitchen on 10/31/23 09:26 AM revealed cheese in refrigerator dated 10/30 with gray/ black spots on it that appears to be moldy and spoiled. Observation in facility's kitchen's dry storage on 10/31/2023 09:45 AM revealed two potatoes in the basket were rotten with multiple gnats on it. Observation in facility's kitchen's dry storage on 10/31/2023 09:58 AM revealed scoop left in the bulk sugar container. An interview with Food Service Manager (FSM) on 10/31/23 09:28 AM revealed that cheese appears to be spoiled. FSM also stated that she would not serve the spoiled cheese. FSM proceeded to discard the cheese in the container. FSM revealed that the cheeses was transferred from the original packaging to the container on 10/25/2023. She was not sure how the cheese was spoiled. FSS also revealed that she was responsible for checking food storage. An interview with FSM on 10/31/23 09:49 AM revealed she was not sure how the potatoes were spoiled but she will throw them out. FSM noted that potatoes were received on 10/25/2023 during the weekly food service delivery. FSM also revealed that produce was checked daily by herself and the cooks; however, it may have been overlooked. FSM also stated that there were no power supply issues in the facility within the last week. She also noted that eating or serving spoiled foods can lead to food borne illness. An interview with FSM on 10/31/23 10:02 AM revealed that the scoop was inside the bulk sugar container, but she was not sure who left it there. FSM revealed that scoop should not be stored inside the container. FSM then proceeded to pick up the scoop and put it over the container lid without 675702 Page 6 of 7 675702 11/02/2023 Brentwood Place Two 3505 S Buckner Blvd Bldg 3 Dallas, TX 75227

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some washing or sanitizing it. FSM noted she would wash and sanitized the scoop before using it again. FSM also stated that using contaminated spoon can cause food borne illness and that it was the responsibility of the cook and herself to maintain utensils in hygienic manner. An interview with [NAME] A on 10/31/23 12:18 PM revealed she usually worked in the afternoon for lunch and dinner service and was responsible for checking dry storage along with another cook. She was also responsible for receiving items from food service as needed and understands every item should be dated and labeled. She was provided with in-services on food storage and food borne illness. She also noted that she has been provide training on infection control like proper hand washing techniques. [NAME] A also revealed that if she observed any food item need to be discarded, she would bring it to the attention of the FSM and take appropriate action as to not serve, cook, transport any spoiled foods. An interview with Dietitian on 10/31/23 02:53 PM revealed that food should be stored per facility protocol and should be free of spoilage, pest infestation and sanitary. Her expectation was that sanitary food practices be followed by all kitchen staff during food storage, food handling and food transportation and any spoiled food should be thrown away as soon as possible. Record Review of facility's food storage policy revealed that Food items will be stored, thawed and prepared in accordance with good sanitary practice. The U.S. Public Health Service, Food Code, dated 2022, reflected the following, .3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include .(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section. 675702 Page 7 of 7