Health inspection·December 7, 2022

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess a resident using the quarterly review instrument not less frequently than once every 3 months for 1 of 18 residents (Resident #228) reviewed for MDS assessments. Residents Affected - Few Resident #228's last MDS assessment was performed on 05/05/22. This failure could lead to the facility being unable to identify the resident's preferences, needs, and functional abilities, which, in turn, could place the resident at risk of receiving inappropriate care or not receiving necessary care. Findings include: Record review of Resident #228's admission Record, dated 12/07/22 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, malignant neoplasm (cancer) of uterus, type 2 diabetes, muscle wasting and weakness, and difficulty walking. Record review of Resident #228's electronic health record MDS tab revealed Resident #228 received an Admission/Medicare - 5 Day MDS assessment on 11/06/21. She received Quarterly MDS assessments on 02/04/22 and 05/05/22 and has not been assessed since that time. Record review of Resident #228's MDS assessment dated , 05/05/22 revealed a BIMS of 15 indicating intact cognition. The MDS indicated Resident #228 received 1-person physical assist in bed mobility, transfer, walking in room/unit, dressing, eating, toileting, and personal hygiene. The MDS further indicated Resident #228 was independent in locomotion on and off the unit in her wheelchair requiring only set up help. In an interview on 12/07/22 at 09:29 AM LVN D said MDS assessments are to be done every 92 days. When asked why Resident #228 has not had an MDS assessment since 05/05/22, she looked up Resident #228 on her computer and said, Oh my gosh! There is no schedule. I can see looking at it here that the schedule that would pop it up when we run it is not there. When asked what a potential negative outcome to the resident might be regarding the assessment not being done, she stated, I don't really foresee a negative outcome because her care plans are still being looked at and updated. She said she could see that if that were not the case, she might find something during an MDS assessment that was not being addressed in the resident's care. During an interview on 12/07/22 at 02:50 PM LVN D said the policy she follows regarding MDS assessments is the RAI Manual. Page 1 of 18 675904 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0638 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/07/22 at 02:20 PM DON said a negative outcome of not having Resident #228's MDS updated timely would be, It captures any changes or new treatments or change of condition and those would be missed if MDS was missed. Record review of facility provided policy titled Care Plans - Comprehensive, dated 12/2010 revealed in part: Residents Affected - Few .2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 675904 Page 2 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to review and revise the comprehensive care plan after each assessment for 1 of 18 (Resident #85) residents reviewed for care plan timing. Resident #85's care plan with a revision date of 10/26/22 did not align with the Quarterly MDS completed on 10/14/22 in the areas of medication and ADL's. This failure could place residents in danger of not receiving needed care. Findings included: Record review of Resident #85's admission record, dated 12/07/22, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, unspecified dementia without behavioral, mood, or psychotic disturbance, major depressive disorder, and generalized anxiety disorder. Record review of Resident #85's Quarterly MDS dated [DATE] revealed a BIMS of 5 which indicated her cognition was severely impaired. Section E of the MDS indicated no behaviors (hallucinations, delusions, physical aggression, verbal aggression, self-harm, rejection of care, or wandering) were exhibited. Section G of the Quarterly MDS noted Resident #85 required extensive assistance by 2 or more staff members for showering/bathing, bed mobility, and transfer. The MDS further noted Resident #85 needed extensive assistance by 1 or more staff members for dressing, personal hygiene, and toileting. Section N of the MDS revealed Resident #85 received insulin injections as well as antipsychotic, antidepressant, and anticoagulant medications 7 of the 7 days of the look back period. Record review of Resident #85's care plan, with revision date of 10/26/22, revealed her care plan listed Zyprexa and Ativan both of which were discontinued before the revision date. The care plan did not list the current antipsychotic medication, Seroquel, which was started more than a month before the care plan revision date. The care plan noted Resident #85 required limited assistance by 1 staff person for showering/bathing, bed mobility, dressing, personal hygiene, and toileting. The care plan stated Resident #85 will maintain current level of mobility (able to walk with walker unassisted). The care plan noted Resident #85 used Ativan related to anxiety. The care plan noted Resident #85 used Zyprexa related to behavior management. Record review of Resident #85's physicians orders on revealed, in part: Seroquel Tablet 100 MG give one tablet by mouth at bedtime for behaviors dated 09/14/22 Seroquel Tablet 50 MG give one tablet by mouth in the morning for behaviors dated 09/15/22. During an interview on 12/07/22 at 08:42 AM LVN D said the facility constantly updated care plans with new medications and changes. She said they updated them every quarter if there was a change that needed updating following the completion of the MDS Assessment. She said, With any new med we update constantly. She acknowledged the need for care plans to be reviewed within 7 days of a completed comprehensive MDS assessment but added, You can't tell (the care plan had been reviewed) unless I changed something. 675904 Page 3 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0657 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/07/22 at 09:29 AM LVN D was asked why Resident #85's care plan mentioned medications that were discontinued in July and September of 2022 if the care plan was reviewed following the Quarterly MDS in October of 2022. She said the care plan should have been reviewed and updated. When asked why it was not reviewed and updated, she replied, I am not sure. I had no help in July, I know, it was just me in July, so it wasn't caught. Residents Affected - Few During an interview on 12/07/22 at 11:23 AM RN G said it has been 6 months since Resident #85 has walked on her own. She said she does not know why Resident #85's care plan from October would say she will continue to be able to walk unassisted. During an interview on 12/07/22 at 02:20 PM thDON said a negative outcome of having the wrong medications listed on Resident #85's care plan would be the family receiving the wrong information. She said, It is important to have the right medications listed. The DON said she did not think it had been 6 months since Resident #85 could walk with her walker. She said she thought Resident #85 was walking with her walker in mid-September of 2022. During an interview on 12/07/22 at 02:41 PM CNA H said she thought it had been 1.5 to 2 months since Resident #85 was able to walk with her walker. Record review of facility provided policy titled, Care Plans - Comprehensive and dated 12/2010 revealed in part: .2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 8. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. 675904 Page 4 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0694 Provide for the safe, appropriate administration of IV fluids 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 parenteral fluids were to be administered consistent with professional standards of practice and physicans orders for 1 of 24 residents (Resident #172) reviewed for physician orders. Residents Affected - Few The facility failed to follow physician orders for completing central line care for resident #172. This deficient practice could result in residents not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident #172's face sheet printed 12-5-2022 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include sepsis (a life threatening complication of an infection), diabetes (a group of disease that result in too much sugar in the blood), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural brain disease), coronary artery disease (damage or disease in the hearts major blood vessels). congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of Resident #172 was admitted on [DATE] and was not due for a completed MDS assessment. Record review of Resident #172's Order Summary Report printed 12-6-2022 with admission date of 11-30-2022 included the following order: Change Central Line Dressing Q7 Days-every day shift every 7 days. Record review of Resident #172's care plan with admission date of 11-30-2022 included the following: Focus: Resident #172 is on antibiotic therapy-Date initiated 12-2-2022 Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy. -Date initiated 12-2-2022 Interventions-there are no interventions for central line dressing care. There are no other care plans for central line dressing care. Record review of Resident #172's treatment administration record dated 12-1-2022 to 12-31-2022 revealed he received his central line dressing change on 12-5-2022. This was 10 days after the date on his central line dressing discovered on 12-5-2022 by this surveyor. During an observation on 12-07-22 at 09:06 AM Resident #172 was in his room sitting at the side of 675904 Page 5 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his bed. Resident #172 was noted to have a CVL dressing to his left upper chest dated 11-25-22. Resident #172 could not remember if the dressing had been changed by the facility. During an interview on 12-05-22 at 09:24 AM (the nurse responsible for Resident #172 this shift) observed Resident #172's CVL dressing and reported that the date on the dressing was 11-25-22 and that was the last time the dressing was changed. LVN A confirmed the dressing was changed 10 days ago and should be changed every 7 days at minimum making this one 3 days late. LVN A reported that CVL dressings were to be changed every 7 days to prevent infections. During an interview on 12-07-22 at 08:26 AM when questioned the DON reported Resident #172's CVL dressing should have been addressed and noted in his head-to-toe assessment when he was admitted , daily, and at least by day two of his admission. That Resident #172's CVL dressing should have been addressed daily in the shift-to-shift report, that communications between staff will need to be better to prevent this from happening again, that they (the floor staff) will need to do better head-to-toe assessments. The DON reported that CVL dressing changes are at least every 7 days per facility policy to prevent complications such as infection and should have an accompanying physicians order. The DON reported that not addressing a resident's CVL dressing change can result in worsening of that condition and the facility does not want to add to that especially with Resident #172 because he was admitted with sepsis and recovery from a major infection. The DON reported that the CVL is for antibiotic therapy and the facility does not want to make a resident's condition worse. Record review of facility provided policy titled Guidelines for Preventing Intravenous Catheter-Related Infections revised August 2014, revealed the following: Catheter Site Dressing Regimens: 2. Use either sterile gauze or sterile transparent, semi permeable membranes (TSM) to cover central or peripheral catheter sites. 4. Change TSM dressing on CVADs every 5-7 days or PRN if damp, loosened, or visibly soiled. This does not require a physician order. 675904 Page 6 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free from unnecessary drugs and included adequate monitoring for high-risk medications for 1 of 18 residents (Resident #85) reviewed for unnecessary medications. Residents Affected - Few Resident #85 was taking Donepezil (anti-Alzheimer) HCI 5 mg one tablet twice a day, Eliquis (anticoagulant) 5 mg once a day, Fluoxetine (antidepressant) HCI 20 mg two tablets once a day, Seroquel (antipsychotic) 100 mg once a day (evening), Seroquel 50 mg once a day (morning), and Depakote (anticonvulsant) Sprinkles Capsule Delayed Release 125 mg 4 capsules twice a day and the facility did not monitor Resident #85's response to or effects of the medications. This failure could place residents on high-risk medications, such as antipsychotics and antidepressants, at risk for unrecognized or untreated side effects or adverse reactions. Findings include: Record review of Resident #85's admission record, dated 12/07/22, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, unspecified dementia without behavioral, mood, or psychotic disturbance, major depressive disorder, and generalized anxiety disorder. Record review of Resident #85's physicians orders revealed, in part: Donepezil HCI Tablet 5 MG give one tablet by mouth twice a day related to Dementia dated 11/07/22 Eliquis Tablet 5 MG give one tablet by mouth one time a day dated 07/10/22 Fluoxetine HCI Tablet 20 MG give 40 MG by mouth one time a day related to major depressive disorder dated 07/10/22 Seroquel Tablet 100 MG give one tablet by mouth at bedtime for behaviors dated 09/14/22 Seroquel Tablet 50 MG give one tablet by mouth in the morning for behaviors dated 09/15/22 Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG give 4 capsule by mouth twice a day related to Major Depressive Disorder dated 07/19/22. During an observation and interview on 12/05/22 11:46 AM Resident #85 was sitting in the day room watching a sermon on TV with several other residents of the locked unit. She was dressed neatly and sitting in a wheelchair. She did not have shoes on her feet, only white socks that looked like men's athletic socks. When asked if she was Ms. (last name of Resident #85) she responded with a questioning look. When asked if she was (first name of Resident #85) she smiled and said, Yes I am. She then looked away and stared blankly to the left and center and would not answer any more questions. During an observation and interview on 12/07/22 at 11:16 AM CNA I was asked how she tracks behaviors and monitors medication side effects for residents on the unit. She demonstrated on her computer where she would document behaviors and side effects. When asked how she knows which residents need 675904 Page 7 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behaviors/medication side effects tracked, she said, It just comes up on the screen of that resident. I'm not sure how it gets there. During an observation and interview on 12/07/22 at 11:55 AM the DON and ADON E and ADON F were in the DON's office. When asked where in the electronic health record behaviors and medication side effects would be documented, ADON E said the MAR/TAR. When asked how they would know to track behaviors/side effects ADON E said it would be in the orders. When told Resident #85 did not appear to have orders to monitor for medication side effects ADON E went to the DON's computer and looked up Resident #85. ADON E said the orders had been entered incorrectly so Resident #85's behaviors/side effects had not been tracked. ADON E asked the DON to enter her password into the computer so she (ADON E) could update the orders. The DON said she would do it and asked ADON E if she just needed to do it for the medication on the screen and ADON E said, No, it looks like for all of them. During an interview on 12/07/22 at 02:20 PM the DON was asked if Resident #85's medication side effects would have been tracked before the orders were corrected. She said, Right, no, that would not have been happening. Record Review of facility provided policy titled, Antipsychotic Medication Use, dated 4/2014 revealed, in part: .6. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; 675904 Page 8 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0757 g. Level of Harm - Minimal harm or potential for actual harm Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); Residents Affected - Few h. Tourette's Disorder; i. Huntington Disease; j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy. 7. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) Behavioral interventions have been attempted and included in the plan of care, except in an emergency . 13. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 14. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; 675904 Page 9 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0757 Level of Harm - Minimal harm or potential for actual harm c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA. Residents Affected - Few 675904 Page 10 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

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; it was determined the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 5 medication carts reviewed for medication storage. 3 insulin medications in the #3 Rehab Unit medication cart were not marked with the date they were opened and accessed 1 insulin medications in the Memory Care Unit medication cart were not marked with the date they were opened and accessed The facility's failure to ensure medications were labeled or stored in accordance with currently accepted professional principles could place residents receiving medication at risk for administration of medication incorrectly or that are ineffective resulting in exacerbation of the disease being treated or the introduction of infection from contamination. Findings include: Resident #1 Record review of Resident #1's face sheet printed 12-6-2022 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include pneumonia (an infection of the lungs), diabetes (a group of diseases that result in too much blood sugar in the blood), anxiety (intense, excessive, and persistent worry or fear), hypertension (a condition in which the force of blood against the artery wall is too high), and heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review revealed Resident #1 was admitted [DATE] and was not due for a competed MDS. Record review of Resident #1 clinical record revealed he had base line care plans for diabetes that addressed insulin administration and was not due for comprehensive care plans. Record review of Resident #1's Order Summary Report printed 12-6-2022 included the following orders: Insulin Glargine Solution 100 units/ml-inject 50 units subcutaneously at bedtime for DM Insulin Lispro Solution 100 units/ml-inject 15 units subcutaneously before meals for DM Resident #2 Record review of Resident #2's face sheet printed 12-6-2022 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include influenza (a common viral infection that can be deadly), sepsis (a life threatening complication of an infection), diabetes (a group of diseases that result in too much blood sugar in the blood), anxiety (intense, excessive, and 675904 Page 11 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some persistent worry or fear), and Alzheimer's (a progressive disease that destroys memory and other important mental functions). Record review revealed Resident #1 was admitted [DATE] and was not due for a competed MDS. Record review of Resident #1 clinical record revealed he had base line care plans for diabetes that addressed insulin administration and was not due for comprehensive care plans. Record review of Resident #1's Order Summary Report printed 12-6-2022 included the following orders: Insulin Lispro Solution 100 units/ml-inject per sliding scale subcutaneously before meals and at bedtime for diabetes. During an observation on 12-05-22 at 11:33 AM of the #3 Rehab Unit medication cart with LVN B the following was noted: 6 insulins present. Resident #1 Insulin Glargine with no marked date of opened or when to discard. LVN B verified the pen was 1/2 empty Insulin Lispro with no marked date of opened or when to discard. LVN B verified the pen was almost empty. Resident #2 Insulin Lispro with no marked date of opened or when to discard. LVN B reported that the pen did not look like it had been accessed but verified that it had been opened. During an interview on 12-05-22 at 11:42 AM LVN B reported that all 3 insulin pens should have been marked with the date they were opened and when they should be discharged . LVN B reported that she did not know why they were not marked, that weekend staff must have restocked and not marked the pens. LVN B reported that she would dispose of and replace the insulin pens. LVN B reported that if someone opens an insulin- they better mark that insulin. LVN B reported that staff need to mark insulin when it is opened so staff will know when the insulin is expired and that she thought most insulins expired in 28-30 days. LVN B reported that an expired insulin will be ineffective and can increase a resident's blood sugar. Resident #111 Record review of Resident #111's face sheet printed 12-6-2022 revealed she was admitted on [DATE] with diagnoses to include diabetes (a group of diseases that result in too much blood sugar in the blood), hypertension (a condition in which the force of blood against the artery wall is too high), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), dementia (a group of thinking and social symptoms that interfere with daily functioning), muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use), and repeated falls. 675904 Page 12 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0761 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #111's MDS revealed a quarterly completed 9-15-2022 listing her with a BIMS of 7 indicating she was severely cognitively impaired, she had a functionality of requiring one to two-person assistance with her activities, and she had an active diagnose in Section I of Type 2 Diabetes. Record review of Resident #111's care plan dated 9-4-2022 revealed the following: Residents Affected - Some Focus: Resident #111 has Diabetes Mellites-Insulin Lispro Goal: Resident will be free from any s/sx of hyper/hypoglycemia. Resident will have no complications related to diabetes. Record review of Resident #111's Order Summary Report printed 12-6-2022 included the following orders: Insulin Lispro Solution 100 units/ml-inject per sliding scale subcutaneously before meals and at bedtime for diabetes. During an observation on 12-05-22 at 12:02 PM of the Memory care unit medication cart with LVN C present. Noted was Resident #111's Lispro insulin pen that was marked with an open date that could not be read and an expiration date of 11-15-22. LVN C verified that the date opened of Resident #111's Lispro insulin pen could not be read, and the date of expirations was 11-15-22. LVN C reported that she thought the insulin pen was out of date. LVN C reported that if an insulin is expired that it will not work, it will not be the right amount. LVN C reported that if used the insulin could result in the resident's blood sugars being too high and residents having hyperglycemia. During an interview on 12-07-22 at 08:23 AM the DON reported that all insulins are to be marked with the open date and discard/expire date when they are opened. The DON reported that she put out an in-service this AM to instruct all nursing personnel on this process to correct the errors noted the day before. The DON reported that if you do not mark the insulin, then you could administer it after the 28 days and the insulin could not be affective. The DON reported that it is the floor staff's responsibility to preorder insulin so that a resident does not receive expired insulin. When asked what consequences could arise from receiving insulin past its use date, the DON reported that residents could have a negative reaction and it could raise their blood sugar. Record Review of the facility provided training/policy titled Medication Storage and Administration Quick Reference Guide initiated 12-7-22 revealed the following: Insulin Vials and Pens-Affix label to the vial or pen with resident identifier, date opened and expiration date. 675904 Page 13 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, and serve food under sanitary conditions in the facility kitchen reviewed for dietary services in that: Food Service Workers A and B were not wearing hair restraints or gloves while in the kitchen; there was unlabeled, undated, and unsealed food in the refrigerators, freezers, and dry storage area; there was expired food in the refrigerators, freezers, and dry storage area; staff's personal drink was on the service line and old food was sitting out; there was one warming cart that was not plugged into a power source; there were no covers on trash cans; and refrigerator and freezer temperature logs were not updated. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: In an observation of the kitchen on 12/5/2022 at 7:20 AM the following was observed: 1. The 2 food service workers (Worker A and Worker B) in the kitchen were not wearing hairnets or gloves. 2. The foods in the main refrigerator(s) and freezer were not labeled or dated with the contents of the containers, nor the received on, opened on or expiration dates; signs posted on all refrigerators and freezers, clearly stated, Cover and Label all Products 3. There were no covers on the trash can(s). 4. Expired 2% milk in individual serving cartons, which were stuck to the box in which they were being held, in the refrigerator. 5. The service cart holding warm pureed breakfast foods was not plugged into a power source. 6. There were dinner items still on trays at the back of the kitchen from the prior evening's (Sunday, 12/4/2022) dinner service. 675904 Page 14 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0812 7. Level of Harm - Minimal harm or potential for actual harm Temperature logs on the holding refrigerator, walk-in cooler and the freezer had not been updated since 12/1/22. Residents Affected - Many 8. There was expired cole slaw dressing, ranch dressing and ancho peppers in the refrigerator, all with an expiration date of 11/21/2022. 9. There was an open box of apples, with 2 rotted, sitting in one of the back sinks. 10. There was a personal bottle of Dr. Pepper sitting on the service line. 11. 3 containers of what appeared to be cranberry sauce with no label or date. 12. 1 large container of cut fruit salad with no label or date. In an observation of the walk-in cooler on 12/5/2022 at 8:00 AM, the following was observed: 1. 1 zip lock bag of turkey and 1 zip lock bag of ham lunch meat; expiration date 11/30/2022 2. 2 open bags of tortillas, one open loaf of bread and 2 open bags of tortilla chips no dates received. 3. 1 zip lock bag of cheese slices, no label or date; not in original box. 4. 1 food service bag of parmesan cheese and 1 food service bag of shredded mozzarella cheese, no label or date, open to the air. 5. 1 container of liquid cranberry juice concentrate with an expiration date of 11/18/2022. 675904 Page 15 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0812 6. Level of Harm - Minimal harm or potential for actual harm 1 open carton of eggs with an expiration date of 11/25/22. 7. Residents Affected - Many 1 food service carton of liquid egg product with an expiration date of 10/18/2022. 8. 1 open box of heads of lettuce and 1 open box of oranges; no dates received. 9. 1 moldy cucumber sitting on cooler shelf 10. 6 large chubs of thawed hamburger meat with expiration dates of 12/1/22 11. 1 large food service bag of thawed, uncooked chicken breasts with an expiration date of 10/24/2022. In an observation of the walk- in freezer on 12/5/2022 at 8:45 AM, the following was observed: 1. 1 large, open food service bag of sausage patties with no date opened or expiration date visible. 2. 1 container of vegetable base mix with an expiration date of 10/7/2021. 3. 1 food service package of queso [NAME] with an expiration date of 12/1/2022. In an observation of the walk-in pantry on 12/5/2022 at 9:00 AM, the following was observed: 1. 1 large bin of breadcrumbs with an expiration date of 12/1/2020. 2. 1 large bin of cornmeal breading with an expiration date of 12/1/2021. 3. 675904 Page 16 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0812 No received dates or visible expiration dates on any of the food service-size cans. Level of Harm - Minimal harm or potential for actual harm In an interview on 12/5/22 at 7:20 AM, the Dietary Manager stated she was usually the one to label and date food, but she was off all weekend. Residents Affected - Many In an interview on 12/5/22 at 7:30AM the Director of Dining said they knew when food was expired and needed to be rotated out of service because they rotated food from the front with the ones from the back. The Dietary Manager and the Director of Dining said the consequences of resident eating expired food was, I guess they could get sick. In an interview at 7:20 AM on 12/5/22, the Dietary Manager was asked why there were no dates or labels on any of the products and her response was, I am usually the one who usually labels and dates everything when it comes in, but I was off all weekend. I asked if the food had just come in and she had no reply. At 7:30AM the Director of Dining was asked how he knew food is expired and needs to be rotated out of service and he responded, We rotate the ones from front with the ones from the back. When asked how he knew it was time to rotate food out of service, He had no reply. I then asked what the consequences might be for the residents who eat this food and they both replied, I guess they could get sick. In an observation on 12/07/2022 at 2:40 PM staff were going through the kitchen, disposing of expired items and labeling and dating remaining items. Record Review of the facility's Food Storage Policy dated July 2014: #6 states, Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). #7 states, All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). #11 states, Functioning of the refrigeration and food temperatures will be monitored at designated intervals, throughout the day, by the Food Service Manager or designee and documented according to state-specific requirements. Record Review of training records and certifications: Dietary Manager:Certifying Board of Dietary Managers-Certificate # 281462 dated 8/24/22 Director of Dining:Learn2Serve Food Safety Management Principles/8 hours CE credit dated 7/16/22 Record review of the USDA Food Code, dated 2017, revealed: Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the 675904 Page 17 of 18 675904 12/07/2022 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0812 PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 675904 Page 18 of 18