Health inspection·November 15, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 2 of 4 shower rooms reviewed for environment. (Shower # 1 and Shower # 4) The facility failed to clean and repair tiles in the facility shower room [ROOM NUMBER] and 4. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: During an interview on 11/14/23 at 3:30 p.m. with Resident # 82, she stated the showers in the shower rooms were bothering her. She said that there was mold growing on the tiles and the caulking was coming apart. She said that there were tiles that were broken and coming off the wall. She said the main reason why she was bothered by the showers was, there was mold or mildew on the tiles, in the broken tiles, and in the caulking on the floor and walls. She said that she wants the showers cleaned, the caulking restored, and the tiles replaced. During an observation on 11/14/23 at 5:05 p.m. shower rooms 1, 2, 3 and 4 were inspected. Shower room [ROOM NUMBER] and 4 had broken tiles, caulking that was missing between the floor tile and the wall tile, and caulking that had worn down and needed replacement. It was observed that both showers 1 and 4 had broken tiles on the wall where it met the floor. It was observed a black substance on the caulking, shower tile grout lines, tiles, and behind the broken tiles. Caulk lines where the floor met the wall was no longer white but was now black in color presumably from mildew and mold. During an interview on 11/15/23 at 10:20 a.m. with the Maintenance Supervisor, he stated he has a maintenance order book that he keeps at the nurse ' s station. He stated all facility staff had access to this book and were supposed to report damage to the building or any items that need fixed. He stated it was not written in the facility maintenance log that shower rooms [ROOM NUMBERS] needed repair to the tile and caulking. He stated it had not been reported to him that the caulking in the shower rooms needed repair and that it had turned black. He stated that the picture the surveyor showed him shows that there was mildew or mold in the shower room. He stated that over time the caulking wore down and would need to be replaced. He said the caulking has to be cut out in order for it to be replaced. He stated that it was also not reported to him that the shower tiles had started to detach from the walls and needed repair. He stated that he has already worked on the shower rooms [ROOM NUMBERS] and they were in good condition. He stated he will replace the caulking in shower rooms [ROOM NUMBERS] as well as replace the tile. He stated he has the tile that goes in the shower rooms, but Page 1 of 18 675966 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0584 he has not yet replaced them. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated she expects staff keep the showers clean and free from mold or mildew. She stated she expects the Maintenance Supervisor to keep the shower room in good working condition which includes intact tile and caulking in the appropriate areas. She stated she wants residents to feel that they live in a clean and comfortable homelike environment and that includes the shower rooms. Residents Affected - Some During an interview on 11/15/23 at 11:23 a.m. with the Director of Nursing, she stated that she expects her staff to keep the shower rooms clean and working. She stated mold or mildew could pose a risk to residents in the form of infections. Record review of the Maintenance Work Log dated from January 1, 2023 to Novemer 2023 revealed maintenance services. The Maintenance Work History Report did not reveal shower room work on the tile or the caulking. Review of a Quality of Life - Homelike Environment facility policy dated May 2017 indicated, Residents are provided with a safe, clean, comfortable, homelike environment .staff shall provide person-centered care that emphasizes the residents ' comfort, independence, and personal needs and preferences .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean, sanitary, and orderly environment . pleasant neutral scents. 675966 Page 2 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

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 observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 21 residents (Residents #37, #78), reviewed for care plans. The facility failed to revise and update Resident #37's comprehensive care plan with new enteral feeding orders. The facility failed to revise and update Resident #78's comprehensive care plan for hospice services. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of the undated face sheet indicated Resident #37 was a [AGE] year-old female that was admitted on [DATE]. Record review of the physician's orders dated 11/13/23 indicated Resident #37 had diagnoses that included: Major depression (persistently depressed mood or loss if interest in activities causing significant impairment in daily life), Diabetes Mellitus type 2 (a chronic condition that affects the way the body processes sugar), Gastro-Esophageal Reflux Disease (stomach content persistently and regularly flows up into the esophagus), Dysphagia (difficulty or discomfort in swallowing), and dementia (impairment of at least 2 brain functions, such as memory loss and judgement). The physician's orders indicated: 5/24/23 Glucerna 1.5 cal, 240 ml bolus (a single dose given all at once) three times a day for feeding. Flush with 60 ml water before and after bolus. Record review of the quarterly MDS dated [DATE] indicated Resident #37 had no speech, rarely understood others, and was rarely understood by others. She had short and long-term memory problems with inattention, disorganized thinking, and an altered level of consciousness that was continuously present. The MDS indicated she had a feeding tube. Record review of the care plan dated 6/1/23 indicated: Resident #37 gets Glucerna 1.5 cal. Give 75 ml/hr via peg tube at night with 25cc/hr water flush. The care plan indicated she required a peg tube due to dysphagia and had impaired cognition. Record review on 11/14/23 at 11:30 AM, of Resident #37's care plan indicated she still received continuous feedings. The care plan did not indicate she was changed to bolus feedings on 5/24/23. Record review of the MAR for Resident #37 dated 10/1/23-10/31/23 indicated: 675966 Page 3 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Glucerna 1.5 cal 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The start date was 5/24/23. Record review of the MAR for 11/1/23-11/30/23 indicated: Glucerna 1.5 cal 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The start date was 5/24/23. 2. Record review of a face sheet dated 11/13/23 revealed Resident #78 was [AGE] years old and was admitted on [DATE] and was initially admitted on [DATE] with diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and stroke. Record review of a handwritten physician's order dated 09/05/23 indicated Resident #78 was admitted to hospice care with a diagnosis of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Record review of the most recent MDS dated [DATE] indicated Resident #78 was receiving hospice care while a resident in the facility. Record review of a care plan last revised on 11/06/23 did not indicate Resident #78 was receiving hospice care. During an interview on 11/14/23 at 12:20 PM, the Regional Nurse said Resident #37's care plan had not been updated to indicate she was currently on bolus feedings. She said Resident #37 was receiving the correct feedings ordered by the physician. During an interview on 11/14/23 at 2:43 PM, the Regional Nurse looked at the care plan for Resident #37 and said she understood it had not been changed to bolus feedings (on 5/24/23) and still indicated a continuous feeding. The Regional Nurse and this surveyor compared the care plan to the physician's orders. She said the care plan did not reflect the current care of the resident. She said the care plan should have been updated with Resident #37's new orders for bolus feedings. During an interview on 11/14/23 at 3:36 PM, RN C said care plans should be updated and accurate because they were the blueprint on how to care for the resident. He said Resident #37 used to be a continuous feeding at night, but he knew the order changed to bolus feedings, so he would not make a mistake even if the care plan was incorrect. He said the care plan should still be accurate. He said the person responsible for making sure the care plans were accurate was the CPC. During an interview on 11/14/23 at 3:40 PM, LVN B said the care plans for residents should always be updated and accurate because that was how their care was dictated. She said if the care plans were wrong, they should be updated as soon as possible. LVN B said the CPC was responsible for making sure the care plans were correct and up to date. She said ultimately all nurses were responsible for making sure the care plans were correct. During an interview on 11/14/23 at 3:44 p.m., a family member of Resident #78 said the resident was receiving hospice care. The family member said hospice was working on providing Resident #78 with a low floor bed. 675966 Page 4 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/14/23 at 3:45 PM, ADON A said the care plans being accurate was very important because that was how they knew how to take care of the resident. She said the person responsible for making sure the care plan was accurate was the CPC. During an interview on 11/14/23 at 4:31 PM, the DON said the care plan for Resident #37 should have been correct and updated so they administered her feeding correctly. She said it was on the MAR correctly, so she believed that the feeding was being given correctly. She said the CPC was responsible for accuracy of the care plans and keeping them updated. She said the ADM had been checking the care plans since October of 2023, but she did not know if she had looked at that Resident #37's. She said moving forward from right now they will be bringing care plans to the morning meeting to go over them and make sure they were correct. She said beginning right now she would be checking all care plans for revisions and accuracy. She said the problem with the care plans being wrong was that the staff may not know to do the right things for the resident. During an observation on 11/14/23 at 4:45 PM, Resident #37 was lying in her bed. Her eyes were open. The head of her bed was up approximately 35 degrees. She did not acknowledge this surveyor or respond to verbal stimulation. During an interview on 11/14/23 04:57 PM, the DON said the Comprehensive Care Plan policy was the only one they had. She said they did not have a policy regarding updating or revising care plans. During a phone interview on 11/14/23 at 5:44 PM, the CPC said Resident #78's care plan should have been updated to show he was on hospice care. She said Resident #37's care plan should have been updated to show she got bolus feedings through her peg tube and no longer got continuous feedings at night. She said it was important for the care plans to be correct because nurses looked at them to see how to care for a resident. She said she was responsible for making sure the care plans were correct. She said she had started checking care plans for accuracy recently, in the last 10 days or so. The CPC said no one was checking her care plans for accuracy but the ADM, DON, and ADON's were going to start checking them for accuracy during the care plan meetings. During an interview on 11/15/23 at 8:10 AM, the DON said the process for updating changes on a care plan was they would take the triplicate for the new orders into the stand-up meeting and go over the new orders at that time. She said they would give the copy to the CPC. The DON said she could not provide the triplicates or the notes from the stand-up meeting because they had been shredded. She said she did not know how Resident 78's hospice order, or Resident #37's feeding change was missed. During an interview on 11/15/23 08:15 AM, RN F said she had worked at the facility for 3 months and always worked PRN. She said Resident #37 had always gotten bolus feedings since she had worked. She said the physician's orders indicated she got bolus feedings. She said it was important for the care plan to be accurate to know how to properly care for the patient. She said she went by a resident's orders and double checked it on the MAR for accuracy. She said the MAR and physician's orders both indicated bolus feedings for Resident #37. During an interview on 11/15/23 08:52 AM, the Regional Nurse provided the updated care plan for Resident #37 that indicated: Resident #37 requires Glucerna 1.5 calorie, 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The care plan revision was dated 11/14/23. During an interview on 11/15/23 09:22 AM, the MDS nurse said she did not do anything regarding care 675966 Page 5 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0657 plans. She said care plans were the responsibility of the CPC. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 09:39 AM, the ADM said the new process for care plans as of 10/24/23 was to discuss any changes at the morning meetings with the ADON's, DON, and herself. She said the DON and ADON's were currently auditing care plans, but they had not gotten to Resident #37 or Resident #78's care plan yet. She said the new process was to compare the consolidated physician's orders with the care plans to make sure nothing was missed, and the care plan was correct. The ADM said the CPC was responsible for making sure the care plan was accurate but ultimately, as the ADM she was responsible. Residents Affected - Few Review of a Care Plans, Comprehensive Person-Centered facility policy dated December 2016 indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas .Assessments of residents are on-going and care plans are revised as information about the residents and the resident's condition change . 675966 Page 6 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide the necessary services to maintain personal hygiene for 2 of 21 residents reviewed for ADLs. (Resident #3 and Resident #72) Residents Affected - Few The facility failed to remove facial hair from female Resident #3. The facility failed to shave facial hair for male Resident #72. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of Resident #3's admission Record dated 03/15/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Physical Debility (General debility is a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions), Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), and Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Record review of Resident #3 ' s Quarterly MDS dated [DATE] revealed a BIMS with a score of 5, which indicated resident #3 has severely impaired cognition. The MDS also revealed, Resident #3, required limited assistance with personal hygiene. Resident #3 required one-person physical assistance with personal hygiene, including shaving. Record review of Resident #3's Care Plan dated 6/21/23, revealed a problem initiation on 3/31/23 resident requires assistance with ADL care related to diagnosis of Dementia. Resident #3 ' s care plan did not show that she refused care. During an observation and interview on 11/13/23 at 10:16 a.m. Resident #3 was observed lying in her bed. She presented with 10 to 15 chin hairs and mustache hairs that were approximately one inch long. She stated that she does not remember the last time she was shaved. She stated that she does not shave herself. She stated that she would prefer to be shaved and not have any facial hair. During an interview and observation on 11/14/23 at 8:30 a.m. Resident # 3 was observed with facial hair. During an interview on 1/15/23 at 9:31 a.m. RN F, she stated the CNAs were responsible to shave residents. She stated CNAs can shave a resident when they give the resident a bath. She stated dependent residents were not able to shave themselves on their own, they require assistance. She stated that she thinks that it was reasonable for a female to want to be clean shaven. She stated that the resident however will need to allow the staff to shave them without refusing. During an interview on 11/15/23 at 09:44 a.m. CNA G stated the CNAs and nurses were responsible for ADLs for dependent residents. She stated some residents refuse ADL care. She stated that if a 675966 Page 7 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident refuses ADL care staff can encourage residents so that care can be provided. CNA G stated the names of resident ' s that refuse care. Resident #3 was not included. CNA G worked on Resident #3 ' s hall. During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated residents who were dependent for ADLs should have their facial hair shaved by staff. She stated it was staff ' s responsibility to ensure that residents who were dependent for ADLs were groomed. She stated unless a resident refuses staff should ensure residents were groomed properly and according to their care plan. She stated resident ' s care plans should reflect if they refuse care. During an interview on 11/15/23 at 11:23 a.m. with the DON, she . She stated it was the responsibility of CNAs to shave residents that were/are dependent for care. She stated nurses should ensure that the CNAs were/are completing these tasks and they too are overseen by the ADONs. She stated it was reasonable that a female resident would not want facial hair. 2. Record review of a face sheet dated 11/15/23 revealed Resident #72 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including muscle weakness, high blood pressure, and Parkinson ' s Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of the most recent MDS dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #72 was totally dependent on staff for personal hygiene. Record review of a care plan last revised on 09/06/23 did not indicated Resident #72 ' s need for assistance with personal hygiene or shaving. Record review on nurse ' s notes from 11/01/23 to 11/15/23 did not indicate Resident #72 had refused care. Record review of CNA-ADL Tracking Form dated 11/2023 indicated Resident #72 had received total assistance with personal hygiene on 11/01/23 - 11/14/23. During an observation and interview on 11/13/23 at 10:09 a.m., Resident #72 was in bed. The resident had unkept facial hair extending down onto his neck. He said staff did not shave him as often as he would like. He said he prefers a goatee and to clean shaven around the goatee. During an observation on 11/14/23 at 10:06 a.m., Resident #72 was in bed. The hospice CNA and a facility CNA were assisting Resident #72 with dressing. The resident had unkept facial hair extending down onto his neck. During an observation and interview on 11/15/23 at 8:06 a.m., Resident #72 said that staff never shave him. He said staff do not offer to shave him. He said he got a bath on 11/14/23 and still was not shaved. The resident had unkept facial hair extending down onto his neck. Resident #72 said to the surveyor, I thought you weren ' t going to come back to see about this. During an interview on 11/15/23 at 9:07 a.m., CNA K said male residents were supposed to be shaved on shower days. She said Resident #72 was very picky about who shaved him. She said he would let her shave him. She said staff should offer for him to be shaved on his bath days. She said his bath 675966 Page 8 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0677 days were Tuesdays, Thursdays, and Saturdays. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 at 9:14 a.m., LPN L said staff should offer to shave male resident on their bath days and as needed. Residents Affected - Few During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected Resident #72 to have been shaved on his bath days and as needed. She said the hospice aide usually shaved him and she was not sure why he had not been shaved. She said not being shaved could be a dignity thing. During an interview on 11/15/23 at 10:46 a.m., the Administrator said she would have expected Resident #72 to have been shaved. She said hospice was responsible for his baths. She said staff should have offered to shave him and shave him anytime he asked. She said she had visited with him, and he had asked to be shaved. She said Resident #72 not being shaved could make him uncomfortable. She said the beauty shop also provided shaves to the resident. Review of a Quality of Life, Activities of Daily Living (ADLs)/Maintain Abilities facility policy dated 11/28/2017 indicated, .To appropriately address resident and facility practices that would affect the resident ' s ability to attain and maintain his/her practicable well-being .The facility must provide the necessary care and services, based on the comprehensive assessment of a resident and consistent with the resident ' s needs and choices, to ensure that a resident ' s abilities in activities of daily living do not diminish unless circumstances of the individual ' s clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility must provide care and services, in accordance with the previous paragraph, for the following activities of daily living .Hygiene .grooming . 675966 Page 9 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Resident #24 and #55) reviewed for respiratory care and services. Residents Affected - Few The facility failed to ensure Resident #24's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #55. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #24's face sheet, dated 11/14/23, indicated she was a [AGE] year-old female, admitted to the facility 09/13/23. Her diagnoses included polycythemia vera (a rare blood disorder in which there is an increase in all blood cells, particularly red blood cells), and asthma (a disease in which the airways clog and narrow, making it hard to breathe). Record review of Resident #24's admission MDS assessment , dated 09/20/23, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. She did not exhibit behavior of rejection of care. Record review of Resident #24's undated physician's orders indicated she had an order for oxygen via nasal cannula 2 L as needed. The start date was 09/28/23. Record review of Resident #24's undated care plan indicated a focus of resident requires the use of oxygen as needed. The focus was last revised on 10/25/23. Interventions included oxygen as ordered. During an observation on 11/14/23 at 04:20 PM, Resident #24 was in her room lying in her bed. She had oxygen in place via nasal cannula. The oxygen concentrator at her bedside was set to 3.5 LPM. During an observation on 11/15/23 at 08:07 AM, Resident #24 was in her room lying in her bed. She had oxygen in place via nasal cannula. The oxygen concentrator at her bedside was set to 3.5 LPM. During an interview on 11/15/23 at 09:25 AM, LVN H said she was assigned to Resident #24 on 11/15/23. She said Resident #24 had an order for oxygen as needed. She said the order indicated Resident #24's oxygen concentrator should have been set at 2 LPM. She said the concentrator should not have been set at 3.5 LPM. She said the oxygen concentrator should be set to the ordered rate. She said the resident could suffer CO2 overload and decreased respiratory drive. She said no one was responsible for ensuring the oxygen concentrators were set at the ordered rate other than the nurse. During an observation on 11/15/23 at 09:33 AM, Resident #24 was lying in bed in her room. She had oxygen in place via nasal cannula. The concentrator at her bedside was set at 3.5 LPM. 675966 Page 10 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/15/23 at 9:52 AM, ADON J said she expected Resident #24's oxygen concentrator to be set at the ordered rate. She said if Resident #24's oxygen was set too high she could overexert herself and suffer complications. She said the nurse was responsible for ensuring the oxygen rate was set correctly throughout their shift. She said the ADONs and charge nurses were responsible for ensuring the oxygen rate was set correctly. She said all licensed personnel were responsible for ensuring the oxygen rate was set correctly. During an interview on 11/15/23 at 09:55AM, the DON said she expected Resident #24's oxygen to be set at the ordered rate. She said Resident #24 could become dependent on the higher dose of oxygen. She said the nurse was responsible for ensuring the oxygen was set at the ordered rate. She said the ADONs were also responsible for checking the oxygen was set at the ordered rate. During an interview on 11/15/23 at 09:57 AM, the Administrator said she expected Resident #24 to be given the ordered dose of oxygen. She said she expected the nurses to keep an eye on the oxygen rate. She said the resident could suffer a negative effect if the rate was set at the wrong rate. 2. Record review of an undated face sheet revealed Resident #55 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Chronic Obtrusive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Palpitations (feelings or sensations that your heart is pounding or racing), Dyspnea (difficult or labored breathing). Record review of the Quarterly MDS dated [DATE] revealed Resident #55 had a BIMS score of 7, which indicated Resident # 55 has severely impaired cognition. Resident #55 was coded as receiving oxygen therapy. Resident #55 required limited assistance with ADLs. Record review of Resident #55 ' s care plan revised on 2/10/21 shows that she receives oxygen as ordered for PRN shortness of breath. Care plan stated that staff are to, Ensure oxygen concentrator is clean and in good working order. During an observation and interview on 11/13/23 at 10:16 a.m. Resident #55 ' s oxygen concentrator external filter was obstructed with dust and debris. Resident #55 stated she used the oxygen concentrator. She stated she did not remember the last time someone cleaned the machine nor the filter on the machine. Resident #55 was observed with the nasal cannula attached to the concentrator on her bed indicating that she uses the device. During an observation on 11/15/23 at 9:00 a.m. Resident #55 ' s oxygen concentrator external filter had yet to be cleaned or replaced. The filter was obstructed with dirt and debris. During an interview on 11/15/23 at 9:31 a.m. with RN F, she stated that the night shift nurses were responsible to change out the oxygen concentrator filters but she wasn ' t sure. She stated she does not look at the concentrator filters. During an interview on 11/15/23 at 9:44 a.m. with CNA G, she stated that it was not her responsibility or that of CNAs to clean or change the filters on oxygen concentrators. She stated she knows what the filter looks like and its location. She stated she was able to report if a filter was dirty to a nurse. During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated. She stated it wasis the nurse ' s responsibility to ensure that oxygen concentrator filters wereare cleaned and 675966 Page 11 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few replaced when needed. She stated that there should not be a buildup of dust on the external filters. She stated that a resident could become ill if the filters wereare not kept clean and free from dust and particles. During an interview on 11/15/23 at 11:23 a.m. with the Director of Nursing, she stated it was the nurse ' s responsibility to ensure that the external filter for the oxygen concentrator was free from dust and debris. She stated that residents were placed at risk for respiratory issues, and it could cause the machine to not work properly. She stated it was the facility ' s policy to ensure that respiratory equipment was in a good and working order. Record review of facility policy titled Oxygen Administration revised in October of 2010 revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol Review the resident's care plan to assess for any special needs of the resident Assemble the equipment and supplies as needed. 675966 Page 12 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 21 residents reviewed for pharmacy services. (Resident # 73) The facility failed to provide adequate supervision for Resident #73 during medication administration. This failure could place residents at risk for inaccurate drug administration. Findings included: Record review of the face sheet 11/14/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including high blood pressure, chronic obstructive pulmonary disease (chronic lung disease), and low back pain. Record review of physician's orders dated 11/14/23 did not indicate Resident #73 could safely administer his own medications. Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #73 was cognitively intact. The MDS indicated Resident #73 was taking medications for depression and an opioid (pain medication). Record review of a care plan revised on 10/24/23 indicated Resident #73 was at risk for side effects related to the use of analgesics (drug to relieve pain), sedatives/hypnotics, anti-hypertensive/cardiac medication, multivitamins, and respiratory drugs. The care plan indicated the resident had chronic pain. There was an intervention for medication as ordered. There was no indication that Resident #73 could safely administer his own medications. Record review of a Resident #73's Medication Administration Record for November 2023 indicated on the morning of 11/13/23 Resident #73 was administered Tylenol #3 (pain medication), Amlodipine 10 milligram tablet (blood pressure medication), Folic Acid 1 milligram tablet (a vitamin used to treat anemia), Klor-Con 20 milliequivalent extended-release tablet (potassium), Loratadine 10 milligram tablet (allergy medication), Montelukast Sodium 10 milligram tablet (a respiratory medication), a multi-vitamin, Tamsolosin 0.4 milligram capsule (medication for an enlarged prostate), Thiamin 100 milligram tablet (vitamin B1), Depakote 250 milligram delayed release tablet for being verbally aggressive, Magnesium 400 milligram tablet (a mineral), Gabapentin 300 milligram capsule (medication for nerve pain), and Sodium Chloride 1 gram tablet (an electrolyte replenisher). There was an order on the record that indicated, May give AM meds at 9:30 a.m. During an observation and interview on 11/13/23 at 10:11 a.m., Resident #73 was sitting in bed with his bedside table in front of him. There was no staff present in the room. There were 7 pills sitting on a napkin on the bedside table. The resident took one pill in front of the surveyor. One pill was pink, 4 were white, one was yellow and brown. The resident said the medication aide let him take them on his own. He said the staff had supervised him while he took his pain medication. 675966 Page 13 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/14/23 at 2:56 p.m., Mediation Aide D said she did leave the pills with Resident #73 on 11/13/23. She said he swallowed his medication real slow and so she went back and forth between residents to make sure he took his medicine. She said sometimes she saved him for last and she stood in the room to make sure he took the medications. She said she was not sure if he had a safe medications administration assessment. She said she did go back and check because she knew it was against state rules to leave medicines with residents. During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected the medication aide to have stayed in Resident #73's room with him during medication administration. She said he had no safe self-medication administration assessment of any kind and medications were to be given by the medication aide or nurse. She said Resident #73 being left alone to self-administer his medications, he could throw them away or choke on them. She said since the administration was not observed by staff, they would not know if he even got his medications. During an interview on 11/15/23 at 10:46 a.m., the Administrator said she would not have expected Resident #73 to have been self-administering his medications while staff were not in the room. She said the resident could take the medications wrong or not take them at all. Review of a Administering Medications facility policy dated December 2012 indicated, .Medications shall be administered in a safe and timely manner .Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so .Residents may self-administer their own medications 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 safely . 675966 Page 14 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

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, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 21 reviewed. (Resident #73) The facility failed to securely store over the counter medications for Resident #73. This failure could place residents at risk for adverse reactions. Findings included: Record review of the face sheet 11/14/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including high blood pressure, chronic obstructive pulmonary disease (chronic lung disease), and low back pain. Record review of physician's orders dated 11/14/23 for Resident #73 did not indicate an order for Flonase Nasal Spray. There was an order dated 09/07/23 for Symbicort Inhalation Aerosol 160-4.5 micrograms/actuations 2 puffs inhale orally two times a day related to chronic obstructive pulmonary disease. Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #73 was cognitively intact. Record review of a care plan revised on 10/24/23 indicated Resident #73 was at risk for side effects related to the use of respiratory drugs. There was an intervention for medication as ordered. During an observation and interview on 11/13/23 at 10:11 a.m., Resident #73 was sitting in bed. There was a bottle of Flonase nasal spray and an inhaler at bedside. The inhaler was white and orange. There was no label identifying to type of inhaler or resident identifying information. The Flonase did not have a resident identifying label. The resident said he kept the two medications on his bedside table so he could use them during the day when he needed them. The resident did have a roommate that was not in the room at this time. During an observation on 11/14/23 at 8:26 a.m., Resident #73 was resting in bed. The bedside table was within reach of the resident. There was a bottle of Flonase nasal spray and an inhaler at bedside. The inhaler was white and orange. There was no label identifying to type of inhaler or resident identifying information. The Flonase did not have a resident identifying label. The resident did have a roommate that was not in the room at this time. During an interview on 11/14/23 at 2:56 p.m., Medication Aide D said Resident #73 always had Flonase and an inhaler beside his bed. She said she had not reported this to the charge nurse. During an interview on 11/14/23 at 3:44 p.m., the Administrator said 73's family member told her they had brought the Flonase and inhaler to the facility and did not think anything about it. She said if staff saw the medications in the room it would have been wise to have checked his care plan. But we should all know OTC (over the counter) medications were not allowed at bedside. 675966 Page 15 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/14/23 at 3:58 p.m., a family member of Resident #73 said they bought the Flonase and inhaler to Resident #73 a few months ago from home. He said the inhaler was just an over-the-counter inhaler that you get from the store. They said Resident #73 had asked them to leave them both because he used them several times a day. He said when he had visited over the last few months, they had been sitting on the bedside table so Resident #73 could reach them. He said when he brought them to the facility, he did not tell any staff and he said he did not know Resident #73 could not have them. During an interview on 11/15/23 at 9:07 a.m., CNA K said she had never seen medications sitting on Resident #73 bedside table. She said any staff that saw medications on a bedside table should report it to the charge nurse. During an interview on 11/15/23 at 9:14 a.m., LPN said she had not noticed any medications in Resident #73's room. She said if she saw any medications at bedside, she would collect them unless there was an order by a physician. During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected over the counter medications to have been locked up and not left at the resident's bedside. She said she looked at the inhaler and it was not labeled, and she was not sure what kind of inhaler it was. She said the resident told her it was Symbicort, but a family member said it was an over-the-counter medication. She said the two medications were destroyed. She said over the counter medications could lead to the resident not taking the appropriate dose or another resident using the medications. During an interview on 11/15/23 at 10:46 a.m., the Administrator said the medications left at the bedside of Resident #73 could have had a contraindication to the medications he was on and could cause illness. Review of a Storage of Medications facility policy dated April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .the nursing staff shall be responsible for maintaining medication storage . 675966 Page 16 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. Residents Affected - Many The facility failed to ensure all food items were labeled and dated. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on 11/13/23 at 8:53 a.m., there were 14 bags of a light brown triangle shaped food item in the pantry with no date or label. During an observation on 11/13/23 at 8:54 a.m., in the walk-in freezer there was 1 bag of round beige colored unknown food items on the floor with no label. There was 1 bag of square light brown unknown food items with no date or label. There were 2 bags round beige colored food item no date or label. There was 1 plastic bag of unknown frozen small round off white food items with no date or label. During an observation on 11/13/23 at 8:56 a.m., in the walk-in cooler there were 6 bags of a yellow liquid with no label. There was 1 gallon of orange juice with a best by date of 10/28/23. There were 2 bags of whipped topping with no date. There were 2 bags of green leafy vegetables with no label. During an observation on 11/13/23 at 9:00 a.m., there was a sign hanging on the refrigerator in the kitchen, Nothing goes in here without an in and out date and label. Dietary Supervisor. During an observation on 11/13/23 at 9:01 a.m., the dishwasher testing strips had an expiration date of August 1, 2019. During an observation on 11/13/23 at 9:03 a.m., in the ice machine there was a black substance, that flaked off when touched, in the seams of the metal pieces in the top of the ice machine over the ice. During an interview on 11/15/23 at 8:55 a.m., the Dietary Manager said all kitchen staff were responsible for dating and labeling foods. She said everything was supposed to be first in and first out. She said as the food items were put away all foods should be dated and labeled. She said undated food could be expired or old. She said food that was too old could cause illness. She said the dishwasher testing strips expired before she became the dietary manager. She said she was not aware she was responsible for cleaning the ice machine. She thought maintenance was responsible. During an interview on 11/15/23 at 9:20 a.m., the Maintenance Supervisor said he said he was responsible for cleaning the ice machine. He said he cleaned the ice machine once every 6 months. He said he did check the ice machine once a month. He said he did not have an ice machine check list. He 675966 Page 17 of 18 675966 11/15/2023 The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many said the cleaning of the ice machine was not documented. He said he thought he had last cleaned the ice machine in August or September when repairs were done on the machine. It said the previous Dietary Manager did clean the ice machine at times. During an interview on 11/15/23 at 10:46 a.m., the Administrator said the dietary department was responsible for dating and labeling food items. She said anytime any food item was opened or removed from a box it should be dated and labeled. She said all foods received from a vendor should be dated. She said out of date foods could make a resident ill. She said the dietary department and maintenance were both responsible for keeping the ice machine clean. She said the ice machine not being kept clean could cause resident to receive contaminated/dirty ice. Review of a Sanitization facility policy dated October 2008 indicated, .The food service area shall be maintained in a clean and sanitary manner .all utensils, counters, shelves and equipment shall be kept clean .Ice machines and ice storage containers will be drained, cleaned and sanitized . Review of a Food Receiving and Storage facility policy dated July 2014 indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such food will be rotated using a first in - first out system .All food stored in the refrigerator or freezer will be covered, labeled and dated . 675966 Page 18 of 18