Health inspection·November 19, 2025

F 0641 Ensure each resident receives an accurate assessment. 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 ensure an assessment accurately reflected a resident's status for 1 (Resident #5) of 12 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #5 for the use of CPAP on her 09/01/25 quarterly MDS. This failure could result in residents not receiving correct care and services. Findings include: Record review of Resident #5's face sheet printed 09/23/25 revealed she was a [AGE] year-old female resident admitted to the facility originally on 06/22/23 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and sleep apnea (a common disorder that causes your breathing to stop or get very shallow). Record review of Resident #5's last MDS was a quarterly assessment completed 09/01/25 listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring supervision/touching assistance with most of her activities of daily living. Section O - Special Treatments, Procedures, and Programs: Resident #5 was not marked as having any Non-invasive Mechanical Ventilation. Record review of Resident #5's care plan with admission date of 07/05/23 revealed the following: Focus: RESIDENT REQUIRES THE USE OF CPAP/BIPAP R/T SLEEP APNEA Facility has ordered several different masks and resident has not been happy with any of them. Date Initiated: 12/12/2023. Revision on: 07/31/2025. Interventions/Tasks: RESIDENT WILL USE DEVICE AS ORDERED. Date Initiated: 12/12/2023. Revision on: 12/12/2023. Record review of the clinical record for Resident #5 revealed an Order Summary Report with active orders as of 09/23/25 with the following order:- O2- OXYGEN- CPAP- O2 CPAP/BIPAP MASK @ 11% at bedtime related to SLEEP APNEA, UNSPECIFIED (G47.30) O2 OXYGEN CPAP VIA MASK SETTINGS @ 11 EVERY NIGHT AT BEDTIME. Phone Active 06/22/2023. Record review of the Treatment Administration Record 08/19/25 to 09/01/25 for Resident #5 revealed she received her CPAP therapy at 8:00 PM 11 times during the MDS required 14-day look back period. During an interview on 09/24/2025 at 1:41 PM Resident #5 reported she had CPAP up until about 6 months ago when she started having trouble with the machine and the company went bankrupt, and she could not get a replacement. Resident #5 reported she was having trouble with her mask and the tubing so the Dr said, let's just scrap the whole thing and start over. Resident #5 reported the facility had been trying to get all her records to include her previous 4 sleep studies from the hospital and they were scheduling a new sleep study. During an interview on 09/24/2025 at 1:59 PM the Administrator reported Resident #5 was on CPAP therapy and had a history of often refusing to wear her CPAP mask. The Administrator reported that was documented in Resident #5's care plan and she has been offered several different types of masks and she has not been wearing them on a regular basis. During an interview on 09/25/2025 at 9:32 AM the MDS Coordinator reviewed Resident #5 last MDS and reported Resident #5 was not marked for CPAP therapy due to the MDS did not require the facility to address her CPAP therapy on the comprehensive assessment. When the surveyor asked the MDS coordinator to review the RAI instructions the MDS Coordinator reported she had misunderstood the instructions Residents Affected - Few Page 1 of 5 675970 675970 11/19/2025 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and the CPAP or BiPAP were to be addressed as non-invasive mechanical intervention. The MDS coordinator reported that she interviewed Resident #5 who told her she never used a CPAP and that was why the MDS coordinator did not address CPAP therapy on the quarterly MDS assessment. The RRC (present for the conversation) reviewed Resident #5's chart and verified Resident #5 was documented on the 14-day look back period as receiving her CPAP therapy but not every night. Both the MDS Coordinator and the RRC discussed Resident #5 and both reported Resident #5 had a history of frequently changing her story and her condition. The RRC reported not addressing the CPAP therapy would not have affected the reimbursement rate on the older version of the MDS assessment but the new one was a different story. The MDS Coordinator reported not addressing the CPAP therapy on the MDS would not affect the resident care because they still get the same care. During an interview on 09/25/2025 at 9:58 AM the Corporate RN reported the previous DON and ADON resigned effective last week. The Corporate RN reported she expects MDS assessments to accurately reflect a resident's status so there would be a continuum of care and everyone would be on the same page, so the residents' care would be consistent. The Corporate RN reported the facility would follow the RAI manual for completion of all MDS assessments. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 (RAI Manual) revealed the following: SECTION O: SPECIAL TREATMENTS, PROCEDURES, ANDPROGRAMSSteps for Assessment O0110G1, Non-invasive Mechanical VentilatorCode any type of CPAP or BiPAP respiratory support devices that prevent airways from closingby delivering slightly pressurized air through a mask or other device continuously or viaelectronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables theindividual to support their own spontaneous respiration by providing enough pressure whenthe individual inhales to keep their airways open, unlike ventilators that breathe for theindividual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here.This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device. 675970 Page 2 of 5 675970 11/19/2025 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (09/19/2025) of the last 90 days reviewed.The facility did not have an RN working in the facility for 1 (09/19/2025) of the last 90 days reviewed. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advanced care skills available to assist in their care needs.Findings included: Record review of the facility's last 90 days (06/25/2025-09/24/2025) of RN coverage provided by the Corp RN revealed the facility had no RN working in the facility for the following date: 09/19/2025. During an interview on 09/24/2025 at 2:23 PM, the Corp RN acknowledged there was no RN coverage on 09/19/2025 after the DON resigned two days prior. The Corp RN stated she was not aware of the vacancy in coverage and had she known, she could have provided RN services that days. She further stated she did not believe there was a negative outcome from the lack of RN coverage, as she was available by phone. During an interview on 09/25/2025 at 10:12 AM, the ADM stated the DON had just recently resigned and she didn't realize there was no RN coverage on 09/19/2025. The ADM, being an RN, also stated she had a doctor's appointment on that day and was not at work. The ADM stated administration personnel were responsible for ensuring licensed staff coverage. The ADM said she did not feel there was a negative outcome because she was always available by phone if issues arose. During a confidential interview on an undisclosed date and time, the staff stated that a negative outcome for not having an RN on staff every day would be that if a major clinical issue came up in the facility, the correct treatment might not be given. A policy for RN coverage was requested on 09/24/2025 at 2:23 PM and 09/25/2025 at 1:15 PM but was not provided. 675970 Page 3 of 5 675970 11/19/2025 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 7 insulins reviewed to meet the needs of each resident. The medication cart had an inulin bottle that was expired according to the date documented on the bottle of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.Findings include: During an observation on 09/24/2025 at 8:46 AM of the facility's only medication cart (with LVN D present) a bottle of Novolog insulin with the date it was opened/ accessed 8/07/25 (48 days prior to this review). The insulin was one of seven insulins present in the medication cart. All other inulin medications were still within the correct use date. During an interview on 09/24/2025 at 8:50 AM LVN D reported the Novolog insulin bottle was marked opened on 8/07/25, had been accessed and used, and that it should have expired in 28 days. LVN D reported if the inulin medication was expired the resident could have an allergic reaction or received a medication which would not be effective and could affect the resident's treatment. LVN D reported the night nurse from the previous shift reported to her she had checked all the insulins but obviously she had not and she (LVN D) would have to report this to the administrator to be delt with and she (LVN D) would replace the expired insulin bottle right now. LVN D also reported she had been trained by the previous DON on the proper storage of all medications and the previous DON no longer worked for the facility During an interview on 09/25/2025 at 9:54 AM the Corporate RN reported that the previous DON and ADON resigned last week. The Corporate RN reported that all insulins should be marked with the date of when they were opened and when they should expire. The expiration date depended on the type of insulin, and their pharmacy has provided them with literature that was on the medication cart of when each type of insulin should expire after it was opened. The Corporate RN reported if a staff member used an insulin that was expired then that resident would not get the full capacity of the medication.Record review of the facility provided Insulin Storage Guidelines: undated, revealed the following:Brand: NovologExpiration date after opening: 28 days Record review of the facility provided policy titled Expired Medications with Shortened Expiration Dates undated, revealed the following: Procedure:2. The Director of Nursing or other authorized personnel will delegate to the appropriate personnel the task of ensuring that all outdated or expired medications ae removed from the medication cart.4. In the event that a medication has a shortened expiration date once opened the medication (open-dated) will be labeled with the date opened. 675970 Page 4 of 5 675970 11/19/2025 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses.Findings included:Observation of the freezer on 09/23/25 at 9:54 AM revealed the following:1. (1) gallon bag of purple unidentified food with no label or date.2. (1) container of lime sherbert, with visible freezer burn, the lid not secured tightly, and an expiration date of 09/09/2025.3. (1) bag of ready to eat hamburger patties stored open to air, out of the original packaging, with ice crystal present, and no label or date.4. (1) large zip top bag of brown frozen liquid, no label or date5. (1) large bag of meat, no label or date.6. (1) large zip top bag of raw chicken legs and wings, no label.7. (1) large clear bag of pancakes removed from the original packaging with no label or date. In an interview on 09/24/25 at 9:55 AM, DC B stated she had worked at the facility since August 2025, and everyone was responsible for labeling and dating food. She stated a possible negative outcome for not labeling and dating food could be that residents could get sick.In an interview on 09/24/25 at 10:15 AM, DA A stated she had worked at the facility for a long time and everyone who worked in the kitchen was responsible for labeling and dating food. She stated a possible negative outcome for not doing that could be a resident could become sick.In an interview on 09/25/25 at 8:26 AM, the DM stated it was everyone's responsibility to label and date food and ensure expired items were thrown away. She stated if food was not labeled or dated then residents could get bad food and get sick. The DM stated she was responsible for ensuring her staff were following policy.Record Review of Food Storage and Supplies dated 2012 revealed the following:Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. If a frozen food item does not have an expiration date or a dated shipping label it will be dated when received or removed from original packaging. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria . foods with spoilage characteristics should not eaten. Record review of FDA Food Code revision January 18, 2023, revealed the following: 3-302.12 Food Storage Containers identified with common name of food.Working containers holding food or food ingredients that are removed from their original packages shall be identified with the common name of the food. 3-302.11 Packaged and Unpackaged food, Separation, Packaging and segregation.Food shall be protected from cross contamination by storing food in packages, covered containers or wrappings. 675970 Page 5 of 5